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Is a bicaval cannulation strategy advantageous in minimally invasive mitral valve surgery?
Christopher L. Tarola1, Daniel JP Burns1, Stephanie A. Fox1, Sankar Balasubramanian1, Rakesh Gudimella1, Jill J. Gelinas1, Stuart Swinamer1, Michael WA Chu1, Linrui R. Guo1, Alan Menkis2, Bob Kiaii1.
1London Health Sciences Center, Western University, London, ON, Canada, 2Winnipeg Regional Health Authority, University of Manitoba, Winnipeg, MB, Canada.
BACKGROUND
Minimally invasive mitral valve surgery (MIMVS) is a common approach to treating mitral valve (MV) pathology, and outcomes are comparable to conventional median sternotomy techniques. Given the anatomic constraints during MIMVS, adequate venous drainage is critical to ensure optimal surgical exposure. The conventional MIMVS venous cannulation strategy utilizes a single 2-staged femoral venous cannula placed in the right atrium or superior vena cava (SVC). We compared operative and clinical outcomes between patients who underwent femoral and bicaval venous cannulation strategies to investigate whether increased venous drainage affected patient outcomes.
METHODS
All patients who underwent MIMVS (245 MV repair, 11 MV replacement) at our institution were retrospectively identified, and stratified by cannulation strategy. The primary outcomes of interest were intensive care and in-hospital length of stay. Secondary outcomes were operative times as well as post-operative clinical outcomes.
RESULTS
Between August 2002 and November 2014, 256 patients underwent MIMVS through a right lateral thoracotomy approach. Sixty underwent single femoral cannulation, while 194 underwent a bicaval approach. There were no significant differences in demographics or comorbidities between the two groups, with the exception of left ventricular grade (Table 1). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were significantly reduced in the bicaval group, 189.6 v. 214.6 minutes (p=0.001) and 128.1 v. 146.9 minutes (p<0.001), respectively. There were no differences in postoperative myocardial infarction, renal failure, wound infection, or in-hospital mortality between groups. However, there was a significant reduction in neurologic complications (3 vs. 1, p=0.043) and reoperation for bleeding (5 vs. 2, p=0.009) in the bicaval group. Length of intensive care (p=0.302) and hospital (p=0.163) stays were not affected by cannulation strategy.
CONCLUSIONSThe addition of a SVC venous drainage cannula in MIMVS was associated with significantly reduced CPB and aortic cross-clamp times. Although there were no differences in length of stay, a bicaval cannulation strategy resulted in fewer adverse neurological outcomes and reoperations for bleeding.
Table 1: Pre-operative patient characteristics.
| Characteristic | Femoral Venous Cannulation Strategy | Bicaval Cannulation Strategy | p-value |
| Age (mean [SD]) | 56.8 [10.6] | 59.7 [13.3] | 0.12 |
| Male | 47 (77%) | 148 (76%) | 0.85 |
| Body Mass Index (mean [SD]) | 27.2 [3.8] | 26.7 [4.6] | 0.29 |
| NYHA Class ≥ 3 | 32 (53%) | 95 (49%) | 0.22 |
| Left Ventricular Grade ≥ 3 | 4 (6%) | 11 (6%) | <0.001 |
| Type II Diabetes | 3 (5%) | 11 (6%) | 1 |
| Pre-operative Creatinine | 0.462 | ||
| 121-180 | 3 (5%) | 7 (3.5%) | |
| ≥180 | 1 (2%) | 1 (0.5%) | |
| Atrial Fibrillation | 13 (21%) | 28 (14%) | 0.19 |
| Chronic Obstructive Pulmonary Disease | 2 (3.3%) | 11 (6%) | 0.74 |
| Previous myocardial infarction | 0 | 1 (0.5%) | 1 |
| Re-operation | 4 (7%) | 6 (3%) | 0.26 |
| Urgent Surgery | 6 (10%) | 26 (13%) | 0.47 |
Presented as frequency (%) unless otherwise specified
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