Best Myocardial Protection Technique In Videoscopic Mitral Valve Surgery - Endoaortic Balloon Occlusion Or Transthoracic Clamping?
Andreas Liebold, Hagen Gorki, Günter Albrecht, Johannes Krefting, Robert Kraft.
Ulm University, Ulm, Germany.
Objective: Videoscopic mitral valve surgery through very small lateral incisions has become popular using either endoaortic balloon occlusion (EABO) or transthoracic clamping (TTC). While BO potentially further reduces surgical trauma it is suspected to be less protective to the myocardium due to balloon migration, volume loss and ineffective cardioplegia. Methods: 473 consecutive patients underwent videoscopic mitral valve surgery via periareolar access (“nipple cut”). Depending on availability an endoaortic balloon occlusion catheter (IntraClude, Edwards Lifesciences, Irvine, CA, USA) was used (EABO, n=367). The remaining patients were operated on using an external transthoracic aortic “Chitwood” clamp (TTC, n=106). Both groups received the same type of antegrade crystalloid cardioplegia (HTK Custodiol). Perioperative data were analyzed with respect to myocardial damage markers (CK-MB and Troponin T, TnT). Results: Both groups were comparable in terms of age, sex distribution, body surface, complexity of surgery, cardioplegia volume, CPB time, and aortic crossclamp time. Both TnT and CK-MB levels were continuously higher in the TTC group compared to the EABO group. Maximum TnT levels were found on POD 1 (TC: 1.059,35 vs. BO: 944.12 ng/L; p=0.48). CK-MB levels in the TTC group showed an increase up to POD 3, whereas CK-MB levels in the EABO group progressively declined from the time of operation. On POD 2 and POD 3 the CK-MB levels were significantly lower in the EABO group (11.75 vs. 37.69 U/L, p=0.003 and 5.49 vs. 26.32 U/L, p=0.005, respectively). Conclusion: At present there is little evidence to support one technique over the other. In terms of myocardial protection, it appears that EABO is at least as safe as TTC - if not even better. Given the less invasiveness, the balloon technique should be the preferred one in videoscopic mitral valve surgery.
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