Manual of Thoracic Endoaortic Surgery

Complications of Port‐Access Cardiac Surgery
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In the case series that described 58, and patients, no aortic dissections occurred. Neurological complications were defined as stroke and transient hemiplegia; however, absolute numbers were not given. Additional theoretical adverse events noted by the advisers were stroke, inadequate myocardial protection or cerebral ischaemia due to balloon misplacement and arterial embolism. This page was last updated: 30 March During major heart surgery, the flow of blood through the heart needs to be stopped temporarily.

Note that this document is not the Institute's guidance on this procedure. Current evidence on the safety and efficacy of endoaortic balloon occlusion for cardiac surgery is adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance. The procedure should only be carried out by a highly experienced team and with the use of transoesophageal echocardiography.

Endoaortic balloon clamping is performed to achieve temporary obstruction of the aorta during cardiac surgery, including mitral valve repair or replacement, and coronary artery bypass grafting CABG. Occlusion of the aorta is required in a number of cardiac operations. This procedure is usually employed during minimally invasive cardiac operations known as port-access surgery that require endovascular aortic occlusion, cardioplegia and left ventricular decompression.

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A balloon catheter is inserted through the skin into an artery normally the femoral artery in the groin and manipulated towards the aortic root. There were no outcomes reported in the literature that related directly to the efficacy of endoaortic balloon occlusion alone. The Specialist Advisers considered key efficacy outcomes to include efficiency of cardioprotection, reduced length of hospital stay, reduced duration of cardiac arrest and avoidance of the use of a cross-clamp from outside, thus potentially reducing stroke risk in patients with very calcified aorta.

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In the case series of patients, there were no significant differences in the incidences of arrhythmias, pulmonary dysfunction, bleeding, renal failure or low cardiac output between those treated with endoaortic balloon occlusion and those treated with transthoracic clamping. In the case series of and patients, myocardial infarction was reported in 1 and 2 patients, respectively.

Although the proportion of external cross-clamping was higher in our cohort, the number of cases performed with endoaortic balloon is relatively high, documenting good and consistent experience. We did not observe any difference in clinical outcomes with one technique over the other. Endoaortic balloon use was associated with increased risk of stroke, although after multivariable adjustment, endoaortic balloon was not predictive of stroke occurrence.

There is, however, a rationale for increased stroke risk with the endoaortic technique because distal dislodgement of the balloon may lead to occlusion of the innominate artery; this complication is generally avoided by bilateral radial artery pressure monitoring and cerebral oximetry based on near-infrared spectroscopy NIRS evaluation. In contrast to other reports 3 - 5 , endoaortic balloon utilization in our study was not associated with longer CPB and cross-clamp time, indicating that with adequate training this technique does not increase the complexity and the duration of the operations 6.

While with the endoaortic balloon time is required to position the tip of the catheter in the ascending aorta under TOE guidance, with the external clamp, a cardioplegia cannula must be placed in the ascending aorta and sometimes repair of the needle-hole is cumbersome and time-consuming. We did not observe any iatrogenic aortic dissection. This was a feared complication in the early era of minimally invasive mitral valve surgery, particularly with the endoaortic balloon 7. Two recent meta-analyses detected an increased incidence of acute iatrogenic aortic dissection when endoaortic balloon is used in minimally invasive cardiac surgery 3 , 4.

In our cohort, both groups used retrograde perfusion through the femoral artery and perfusion pressure were constantly monitored throughout the operation, with particular emphasis at the beginning of CPB, before cross-clamping of the aorta. With the endoaortic balloon catheter occupying part of the cannula lumen, there is a substantial risk of having high jet pressures at the exit of the cannula. When perfusion pressure within the femoral artery line exceeded mmHg, simple adjustments were initially made i. Avoiding extremely high jet pressures from the femoral cannula is essential in preventing retrograde aortic dissection, particularly in patients with atherosclerotic disease and explains why this is not an observed complication nowadays.

Some concerns exist regarding satisfactory myocardial protection with the two settings of aortic occlusion and cardioplegia delivery 8 , 9. In our experience, myocardial damage expressed as cardiac enzymes release was not influenced by aortic occlusion technique. Monodose crystalloid cardioplegia was preferably utilized with the endoaortic technique because balloon positioning in the ascending aorta can only be visualized by TOE when the left atrium is closed, therefore subsequent doses of intermittent cardioplegia may lead to dislodgment of the endoaortic balloon and inadequate myocardial protection.

In the external transthoracic clamp cases, intermittent cold blood cardioplegia has been preferred to avoid further hemodilution. We have previously demonstrated that both crystalloid and cold blood cardioplegia solutions provide adequate protection in minimally invasive cardiac surgery Exposure of the mitral valve is generally well accomplished with both aortic occlusion strategies.

Mitral repair rate was significantly higher in the external cross-clamping group, but this was probably just a casual finding. The use of thoracoscopy and video assistance has become a fundamental part of the technique, particularly since the implementation of 3D endoscopy; it remarkably improves the mitral valve visualization and repair possibilities. The absence of transthoracic clamping and cardioplegia cannulation may facilitate thoracoscopy positioning and visualization. Apart from the common contraindication for EAO, in case of an ascending aorta diameter greater than 40 mm, the choice between the two techniques of aortic occlusion was based mainly on operator preference and naturally affected patient selection.

This is clearly underlined by the significant difference in age and in the rate of redo operations between the two groups.

Elderly patients may exhibit atherosclerotic disease of the peripheral arteries and the thoraco-abdominal aorta, thus justifying the use of transthoracic cross-clamp. On the other hand, the use of EAO allows an even smaller surgical access, being more appealing in the young for aesthetic reasons and less traumatic in frail patients. Furthermore, the EAO system provides fundamental technical advantages in avoiding tissue dissection and is our first choice in redo operations.

Our results showed that EAO and aortic cross-clamping proved to be safe and effective. There was a higher rate of perioperative stroke in the EAO group, but it was statistically non-significant. Rather than looking for the superiority of one of these two techniques, we reported the advantage given by the possibility of handling both endoaortic occlusion and transthoracic clamping and the availability of tailoring the surgical strategy according to individual patient characteristics.

Introduction Minimally invasive cardiac surgery through the right mini-thoracotomy approach has established itself as standard of care for the treatment of pathologies affecting the atrio-ventricular valves 1.

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Total arterial or T-graft revascularization may obviate the need for a proximal anastomosis, coronary revascularization can thus be performed during no-touch OPCAB. Using a commercial snare to remove a balloon: Cut the proximal end of the balloon catheter and advance the snare using the balloon catheter as a wire. In a study by Zingone et al. March ;67— J Thorac Cardiovasc Surg.

Methods Patients We analyzed prospectively collected data of patients who received minimally invasive mitral surgery during the period January and July Overall mortality was 1. There was no difference in day mortality between the two groups.

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Table 3 reports details of all perioperative outcomes. None of these variables retained significance after multivariate analysis.

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No significance was found at multivariate analysis. After multivariate analysis, no significance was found. Minimally invasive mitral valve surgery is gaining full credit after a couple of decades of skepticism received from the vast majority of cardiac surgeons. While reduction of surgical incision through a small thoracotomy is a common element for all minimally invasive approaches, perfusion, cardioplegia strategy and aortic occlusion techniques may vary according to surgeon preference and specific training.

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In this report, we describe our experience on aortic occlusion strategy comparing EAO with external trans-thoracic clamp. This comparison is relatively uncommon, as surgeons and centers usually adopt only one technique and do not master both aortic occlusion strategies. Although the proportion of external cross-clamping was higher in our cohort, the number of cases performed with endoaortic balloon is relatively high, documenting good and consistent experience.

Introduction

We did not observe any difference in clinical outcomes with one technique over the other. Endoaortic balloon use was associated with increased risk of stroke, although after multivariable adjustment, endoaortic balloon was not predictive of stroke occurrence. There is, however, a rationale for increased stroke risk with the endoaortic technique because distal dislodgement of the balloon may lead to occlusion of the innominate artery; this complication is generally avoided by bilateral radial artery pressure monitoring and cerebral oximetry based on near-infrared spectroscopy NIRS evaluation.

In contrast to other reports 3 - 5 , endoaortic balloon utilization in our study was not associated with longer CPB and cross-clamp time, indicating that with adequate training this technique does not increase the complexity and the duration of the operations 6. While with the endoaortic balloon time is required to position the tip of the catheter in the ascending aorta under TOE guidance, with the external clamp, a cardioplegia cannula must be placed in the ascending aorta and sometimes repair of the needle-hole is cumbersome and time-consuming.

We did not observe any iatrogenic aortic dissection. This was a feared complication in the early era of minimally invasive mitral valve surgery, particularly with the endoaortic balloon 7. Two recent meta-analyses detected an increased incidence of acute iatrogenic aortic dissection when endoaortic balloon is used in minimally invasive cardiac surgery 3 , 4. In our cohort, both groups used retrograde perfusion through the femoral artery and perfusion pressure were constantly monitored throughout the operation, with particular emphasis at the beginning of CPB, before cross-clamping of the aorta.

With the endoaortic balloon catheter occupying part of the cannula lumen, there is a substantial risk of having high jet pressures at the exit of the cannula. When perfusion pressure within the femoral artery line exceeded mmHg, simple adjustments were initially made i. Avoiding extremely high jet pressures from the femoral cannula is essential in preventing retrograde aortic dissection, particularly in patients with atherosclerotic disease and explains why this is not an observed complication nowadays.

Some concerns exist regarding satisfactory myocardial protection with the two settings of aortic occlusion and cardioplegia delivery 8 , 9. In our experience, myocardial damage expressed as cardiac enzymes release was not influenced by aortic occlusion technique. Monodose crystalloid cardioplegia was preferably utilized with the endoaortic technique because balloon positioning in the ascending aorta can only be visualized by TOE when the left atrium is closed, therefore subsequent doses of intermittent cardioplegia may lead to dislodgment of the endoaortic balloon and inadequate myocardial protection.

In the external transthoracic clamp cases, intermittent cold blood cardioplegia has been preferred to avoid further hemodilution. We have previously demonstrated that both crystalloid and cold blood cardioplegia solutions provide adequate protection in minimally invasive cardiac surgery Exposure of the mitral valve is generally well accomplished with both aortic occlusion strategies.

Mitral repair rate was significantly higher in the external cross-clamping group, but this was probably just a casual finding. The use of thoracoscopy and video assistance has become a fundamental part of the technique, particularly since the implementation of 3D endoscopy; it remarkably improves the mitral valve visualization and repair possibilities. The absence of transthoracic clamping and cardioplegia cannulation may facilitate thoracoscopy positioning and visualization.