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Efficacy of intraoperative monitoring of limb perfusion with near-infrared spectroscopy in prevention of lower limb neuropathy after minimally invasive cardiac surgery
Kosuke Nakajima, Kazuyuki Nagata, Toshinori Totsugawa, Arudo Hiraoka, Tomoya Oshita, Ryosuke Muraki, Masahisa Arimichi, Hidenori Yoshitaka, Taichi Sakaguchi.
The Sakakibara Heart Institute of Okayama, okayama, Japan.

OBJECTIVE: Lower limb neuropathy (LLN) sometimes occurs after minimally invasive cardiac surgery (MICS) with peripheral perfusion access. As insufficient distal perfusion is a possible cause of this complication, aggressive intraoperative management including alternative perfusion strategies by monitoring lower limb perfusion with near-infrared spectroscopy(NIRS)may be useful.
METHODS: MICS via right mini-thoracotomy was performed in 487 patients between 2009 and 2015. Surgical procedures included mitral valve surgery in 310 patients, aortic valve surgery in 131, and the other procedures in 36. NIRS was used in the recent 227 patients (NIRS group). Occurrence of LLN was retrospectively compared between the NIRS group and the remaining 260 patients (Control group). In most patients, cardiopulmonary bypass (CPB) was established with single femoral arterial access. The size of the femoral arterial cannula was selected based on necessary flow dynamics and the diameter of the femoral artery measured by preoperative contrast-enhanced computed tomography. When the femoral artery was too small, alternative perfusion access was considered, including bilateral femoral artery, the right axillary artery, and central aortic cannulation. In the NIRS group, perfusion status of lower limbs were continuously monitored during the period of CPB, and further alternative strategies were considered when tissue oxygen saturation decreased more than 30% of preoperative values.
RESULTS: The duration of CPB was similar between 2 groups (NIRS vs Control : 170±52 min vs 167±52 min). More patients received intraoperative change of perfusion access in the NIRS group, including additional distal limb perfusion using a small catheter in 5 patients. As a consequence, the incidence of LLN was significantly lower in the NIRS group than the Control group (0.4 % versus 5.5%, p=0.0014).
CONCLUSIONS: Intraoperative monitoring of tissue oxygen saturation with NIRS is useful for optimal lower limb perfusion to prevent LLN after MICS.

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