Axillary Cannulation Technique For Minimally Invasive Mitral Valve Surgery
Erik Cura Stura, Cristina Barbero, Olexander Dyrda, Marco Pocar, Davide Ricci, Giovanni Marchetto, Massimo Boffini, Mauro Rinaldi.
Cittą della Salute e della Scienza di Torino - Molinette, Torino, Italy.
Objective: Minimally invasive mitral valve surgery (MIMVS) requires pre-operative evaluation in order to tailor on the patient the cannulation and clamping strategy. Femoral cannulation is the most used approach, however it should be avoided in case of severe peripheral vasculopathy. In this high risk population, axillary cannulation with anterograde flow could be an alternative approach. Methods: From March 2014 to March 2019 in our institution 625 consecutive patients underwent MIMVS. Based on pre-operative characteristics the patients were allocated in three groups: retrograde arterial perfusion through femoral artery with Endoreturn/Intraclude clamping system (P+EB) was used in 319 (51%) patients, retrograde arterial perfusion through femoral artery with transthoracic clamp (P+XC) in 262 (41.9%) patients and anterograde arterial perfusion through axillary artery with trans-thoracic clamp (P+XC) in 44 (7%) patients characterized by a severe peripheral vasculopathy. The direct cannulation of right axillary artery (without interposition of a tubular prosthesis) was performed through a minimal incision (about 4 cm) that also allows the trans-thoracic clamp placement. Results: The three groups differed significantly in pre-operative characteristics: in P+EB group a higher frequency of previous cardiac surgery (p<0.01), in C+XC group a higher age (p<0.01), BMI (p=0.03) and prevalence of COPD (p<0.01). These differences justify the higher predicted mortality in C+XC group: Logistic EuroSCORE (p<0.01) and EuroSCORE II (p<0.01). There was no significant difference in cardiopulmonary bypass time (P=0.16), although in C+XC group was observed a higher incidence of mitral valve replacement (p=0.03) with a significant reduction in clamping time (p<0.01). In the post-operative period there were no differences in ventilation time (p=0.87), ICU stay (p=0.59) and hospital stay (p=0.54). Post-operative outcomes showed no significant differences: stroke (p=0.86), re-exploration for bleeding (p=0.74), hemodyalisis (p=0.83) and PM implantation (p=0.83). 30-day mortality was comparable between groups (p=0.63). Conclusions: Compared with the other strategies, axillary cannulation with anterograde flow is a safe, effective and reproducible technique and allows to extend the benefits of MIMVS even in patients with severe peripheral vasculopathy.
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