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International Society For Minimally Invasive Cardiothoracic Surgery

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Comparison Of Endo-aortic Balloon Occlusion With External Clamping During Cardiac Surgery
Husam H. Balkhy1, Eugene Grossi2, Bob Kiaii3, Shannon Murphy4, Hiroto Kitahara1, Sloane Guy5, Clifton Lewis6.
1University of Chicago Medicine, Chicago, IL, USA, 2NYU Langone, New York, NY, USA, 3University of California Davis, Sacremento, CA, USA, 4Edwards, Irvine, CA, USA, 5Jefferson University, Philadelphia, PA, USA, 6University of Alabama, Birmingham, AL, USA.

BACKGROUND: Endoaortic balloon occlusion, or endoclamping, facilitates cardioplegic arrest during minimally invasive surgery (MIS). Limited research has shown endoclamping to be as safe as traditional aortic clamping. This study compares outcomes after cardiac surgery utilizing endoclamping as compared with traditional methods of aortic occlusion in a broader, real-world setting. METHODS: 52,882 adults undergoing eligible cardiac surgery (10/2015-3/2020) were identified by administrative data from the Premier Hospital Dataset. Endoclamp MIS procedures (n=419) were 1:3 propensity score matched to similar procedures performed using traditional aortic occlusion methods (primarily external clamping, n=1244). Comparison procedures were selected by procedure type, and absence of: known sternotomy (a proxy for MIS), CABG, or concomitant aortic surgery. Generalized linear modeling measured differences in in-hospital complications [major adverse renal and cardiac events (MARCE, including mortality, new onset atrial fibrillation, acute kidney injury, myocardial infarction, postcardiotomy syndrome, stroke/TIA) and aortic dissection], and length of stay. RESULTS: Mean age was 63 years, and 53% were male (n=882). The majority (93%, n=1543) were mitral valve procedures and the remainder were atrial septal defect, left atrial appendage occlusion and/or tricuspid valve procedures. 1 in 6 (17%, n=285) procedures were robotic-assisted and 1% (n=20) were re-operations at the same index hospital. The endoclamp group exhibited lower MARCE rates as compared to the comparison external clamping group, with borderline difference at p<0.10: 22% vs. 26% (odds ratio (OR)=0.78, p=0.0611). Lower MARCE rates appeared to be driven largely by myocardial infarction (OR=0.14, p=0.0061) and postcardiotomy syndrome (OR=0.27, p=0.0051). No endoclamp patients experienced aortic dissection. Rates of mortality, atrial fibrillation, acute kidney injury and stroke/TIA were not significantly different between the 2 groups. Median length of stay was significantly shorter with endoclamping vs. external clamping methods (incident rate ratio=0.87, p=<0.0001). CONCLUSIONS: Endoclamping was associated with shorter hospital stays, no dissections and comparable low mortality and stroke rates when compared to traditional external clamping techniques in this hospital billing dataset. These results demonstrate the clinical safety and efficacy of endoclamping in a real-world setting. Further studies are warranted.

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