title: Minimally invasive mitral valve surgery without aortic cross-clamping and with femoral cannulation is not associated with increased risk of stroke compared with traditional mitral valve surgery: a propensity score-matched analysis.
abstract: OBJECTIVE
  Open-heart surgery with fibrillatory arrest has been reported to be associated with an increased risk of stroke. We examined whether minimally invasive mitral valve surgery with fibrillatory arrest conferred a higher risk of stroke/transient ischaemic attack (TIA) and other major complications compared with median sternotomy and cardioplegic arrest.
  
  
  METHODS
  Data were collected prospectively for 387 patients who had mitral valve surgery; 239 had a minimally invasive surgical approach and 148 had median sternotomy. All minimally invasive surgeries were performed by surgeons who were experienced in minimally invasive techniques. The effect of operative approach on risk of stroke/TIA and major morbidity was examined. After propensity score matching (PSM) was conducted between the two groups, 76 patients remained in each group.
  
  
  RESULTS
  Before matching, the incidence of stroke/TIA did not differ between patients who had minimally invasive surgery (0.5%, n = 1) and those who had median sternotomy (1.4%, n = 2; P = 0.56). Patients who had minimally invasive surgery had a lower incidence of other major morbidity (0.8%, n = 2) than patients who had median sternotomy (6.1%, n = 9; P = 0.004). After adjustment for age and Society of Thoracic Surgeons predicted risk, there was no effect of operative approach on the odds for stroke/TIA (odds ratio [OR] = 0.41, P = 0.49) or other major morbidity (OR = 0.40, P = 0.31). After PSM, patients were balanced on preoperative characteristics. No patient in either matched group experienced permanent stroke/TIA, and major morbidity did not differ between the two groups (minimally invasive, 1.3%, n = 1; median sternotomy, 1.3%, n = 1; P > 0.99).
  
  
  CONCLUSIONS
  A minimally invasive approach for mitral valve surgery on a fibrillating heart was not associated with a greater incidence of stroke/TIA than was median sternotomy. When performed by highly experienced surgeons, the minimally invasive approach with fibrillatory arrest did not increase the risk of perioperative stroke.
authors: Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA niv.ad@inova.org.
authors: Niv
authors: N
authors: Ad
authors: Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA.
authors: Sari D
authors: SD
authors: Holmes
authors: Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA.
authors: Deborah J
authors: DJ
authors: Shuman
authors: Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA.
authors: Graciela
authors: G
authors: Pritchard
authors: Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA.
authors: Paul S
authors: PS
authors: Massimiano
mesh_terms: D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D008943:Mitral Valve / Q000601:surgery*; D057216:Propensity Score; D011446:Prospective Studies; D012307:Risk Factors; D056346:Sternotomy; D020521:Stroke / Q000209:etiology*
keywords: Cardiac surgical approaches; Minimally invasive technique; Mitral valve surgery