title: Antegrade and retrograde perfusion in minimally invasive mitral valve surgery with transthoracic aortic clamping: a single-institution experience with 1632 patients over 12 years.
abstract: The aim of the present study was to evaluate the impact of a retrograde arterial perfusion (RAP) strategy versus an antegrade arterial perfusion (AAP) strategy in a consecutive, large cohort of patients who underwent minimally invasive mitral valve surgery with transthoracic aortic clamping through a right minithoracotomy.
  
  
  
  Between 2003 and 2015, 1632 consecutive patients underwent first-time minimally invasive mitral valve surgery with transthoracic aortic clamping at our institution; 141 (8.6%) of these patients received retrograde perfusion with femoral artery cannulation, whereas 1421 (91.4%) received antegrade perfusion with ascending aorta cannulation. Logistic regression was used to evaluate outcomes and risk factors for death and stroke between groups.
  
  
  
  The overall frequency of 30-day mortality was 0.7% (13/1632) and was similar between groups (retrograde arterial perfusion RAP 0.7% vs AAP 0.8%; P  = 0.903). The overall postoperative stroke rate was 1.3% (22/1632). The stroke rate was significantly higher in patients receiving retrograde perfusion (3.5% vs 1.1%; P  = 0.005). Risk factors for death were advanced age (odds ratio (OR) = 1.3; P  = 0.004), mitral valve replacement (OR = 3.9; P  = 0.05), emergent procedure (OR = 3.4; P  = 0.014) and conversion to sternotomy (OR = 3.7; P  = 0.001). Multivariable regression analysis revealed that retrograde perfusion was an independent risk factor for stroke (OR = 3.3; P  = 0.004). Other risk factors were conversion to sternotomy (OR = 12; P  = 0.001), active endocarditis (OR = 5.8; P  = 0.07) and hypercholesterolaemia (OR = 2.4; P  = 0.048). Interaction modelling revealed that the only significant risk factor for a neurological event was the use of retrograde perfusion in patients older than 70 years with an atherosclerotic burden (OR = 6.4; P  = 0.033).
  
  
  
  Minimally invasive mitral valve procedures can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications in older patients with atherosclerotic burden. Central aortic cannulation permits avoidance of complications associated with retrograde perfusion and extends the suitability of minimally invasive mitral procedures to those patients who have an absolute contraindication for femoral artery cannulation.
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Murzi
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Alfredo G
authors.initials: AG
authors.lastname: Cerillo
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Gasbarri
authors.affiliation: Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy.
authors.forename: Rafik
authors.initials: R
authors.lastname: Margaryan
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Enkel
authors.initials: E
authors.lastname: Kallushi
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Pierandrea
authors.initials: P
authors.lastname: Farneti
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Solinas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D008943:Mitral Valve / Q000601:surgery*; D010477:Perfusion / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013908:Thoracotomy / Q000379:methods
keywords: Cardiopulmonary bypass; Minimally invasive cardiac surgery; Mitral valve