title: Minimally invasive valve surgery with antegrade perfusion strategy is not associated with increased neurologic complications.
abstract: BACKGROUND
  A Society of Thoracic Surgeons' publication recently associated "minimally invasive" approaches with increased neurologic complications; this proposed association was questionable due to imprecise definitions. To critically reevaluate this issue, we reviewed a large minimally invasive valve experience with robust definitions.
  
  
  METHODS
  From November 1995 to January 2007, 3,180 isolated, non-reoperative valve operations were performed; 1,452 (45.7%) were aortic replacements and 1,728 (54.3%) were mitral valve procedures. Surgical approach was standard sternotomy (28%) or minimally invasive technique (72%). Antegrade arterial perfusion was used in 2,646 (83.2%) patients and retrograde perfusion in 534 (16.8%). Aortic clamping was direct in 83.4%, with endoclamp in 16.4% and no clamp in 0.2%. Patients were prospectively followed in a proprietary database and the New York State Cardiac Surgery Reporting System (mandatory, government audited). A neurologic event was defined as a permanent deficit, a transient deficit greater than 24 hours, or a new lesion on cerebral imaging.
  
  
  RESULTS
  Hospital mortality for aortic valve replacement was 4.0% (sternotomy [5.1%] versus minimally invasive [3.4%] p = 0.13); for mitral procedures it was 2.4% (sternotomy [4.8%] versus minimally invasive [1.8%] p = 0.001). Multivariate analysis revealed that age, female gender, renal disease, ejection fraction less than 0.30, chronic obstructive pulmonary disease, and emergent operation were risk factors for mortality. Stroke occurred in 71 patients (2.2%) (sternotomy [2.1%] versus minimally invasive [2.3%] p = 0.82). Multivariate analysis of neurologic events revealed that cerebrovascular disease, emergency procedure, no-clamp, and retrograde perfusion were risk factors. In patients 50 years old or younger (n = 662), retrograde perfusion had no significant impact on neurologic events (1.6% vs 1.1%, p = 0.57).
  
  
  CONCLUSIONS
  A minimally invasive approach with antegrade perfusion does not result in increased neurologic complications. Retrograde perfusion, however, is associated with increased neurologic risk in older patients.
authors.affiliation: Department of Cardiothoracic Surgery, New York University Medical Center, New York, NY, USA. eugene.grossi@nyumc.org
authors.forename: Eugene A
authors.initials: EA
authors.lastname: Grossi
authors.forename: Didier F
authors.initials: DF
authors.lastname: Loulmet
authors.forename: Charles F
authors.initials: CF
authors.lastname: Schwartz
authors.forename: Brian
authors.initials: B
authors.lastname: Solomon
authors.forename: Sophia L
authors.initials: SL
authors.lastname: Dellis
authors.forename: Alfred T
authors.initials: AT
authors.lastname: Culliford
authors.forename: Elias
authors.initials: E
authors.lastname: Zias
authors.forename: Aubrey C
authors.initials: AC
authors.lastname: Galloway
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D015897:Comorbidity; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications; D006349:Heart Valve Diseases / Q000150:complications / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D008943:Mitral Valve / Q000601:surgery*; D009518:New York / Q000453:epidemiology; D010477:Perfusion / Q000379:methods*; D011379:Prognosis; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D015996:Survival Rate / Q000639:trends