A Retrospective Evaluation of Endo-Aortic Balloon Occlusion Compared to External Clamping in Minimally Invasive Mitral Valve Surgery.

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N = 60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P = 0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.

Transthoracic Aortic Clamp Technique for Port-Only Endoscopic Robotic Mitral Surgery.

OBJECTIVE: Many robotic mitral surgeons utilize right thoracotomy with transthoracic clamping of the aorta, while a smaller number employ a port-only endoscopic approach with endoaortic balloon occlusion of the aorta. We present our technique for a port-only endoscopic robotic approach with transthoracic clamping. METHODS: From July 2019 through December 2022, 133 patients underwent port-only endoscopic robotic mitral surgery with transthoracic clamp aortic occlusion and antegrade cardioplegia. Perfusion was through the femoral artery in 101 patients (76%) and axillary in 32 patients (24%). Clamp technique involved placing the clamp at the mid-ascending aorta, dynamic valve testing to 90 mm aortic root pressure, and closure of the cardioplegia cannula site prior to clamp removal. Indications for clamp utilization over balloon occlusion included both balloon supply issues and aortoiliac anatomy. RESULTS: Mitral repair was performed in 122 patients (92.7%) and mitral valve replacement in 11 patients (8.3%). Mean aortic occlusion time was 92 ± 21.4 min. Mean time from left atrial closure to clamp removal was 8.7 (7.2 to 12.8) min. There were no injuries to the aorta or surrounding structures, mortality, strokes, or renal failure. CONCLUSIONS: For robotic teams with endoaortic balloon capability, this technique may be useful in certain patients with aorto-iliac pathology or limited femoral artery access. Alternatively, robotic teams who employ transthoracic aortic clamping through a thoracotomy may find this technique useful to transition to a port-only endoscopic approach.

Endoaortic balloon occlusion versus transthoracic cross-clamp for totally endoscopic robotic mitral valve surgery: a retrospective cohort study.

Endoaortic balloon occlusion (EABO) and transthoracic cross-clamping have been shown to have comparable safety profiles for aortic occlusion in minimally invasive mitral valve surgery (MIMVS). However, few studies have focused exclusively on the totally endoscopic robotic approach. We sought to compare outcomes for patients undergoing totally endoscopic robotic mitral valve surgery with aortic occlusion via EABO and transthoracic clamping after a period where EABO was unavailable required us to use the transthoracic clamp. Retrospective review identified 113 patients who underwent robotic mitral valve surgery at our facility between 2019 and 2021 with EABO (n = 71) or transthoracic clamping (n = 42). Relevant data were extracted and compared. Preoperative characteristics were similar other than a higher rate of coronary artery disease [EABO: 69.0% (49/71) vs clamp: 45.2% (19/42), p = .02] and chronic lung disease [EABO: 38.0% (27/71) vs clamp: 9.5% (4/42), p < .01] in the EABO group. Median percutaneous cardiopulmonary bypass time, operative time, and cross-clamp time were comparable. Similar rates of postoperative bleeding complications were observed, and no aortic complications were observed. One patient in each group underwent conversion to an open approach. 30-day mortality and readmission rates were comparable. EABO and transthoracic clamp were associated with similar bleeding and aortic outcomes, and mortality and readmission rates were comparable at thirty days postoperatively. Our findings support the comparable safety of the two techniques, which is well documented in studies encompassing all MIMVS techniques, within the specific context of the totally endoscopic robotic approach.

Transthoracic clamp versus endoaortic balloon occlusion in minimally invasive mitral valve surgery: a systematic review and meta-analysis.

This systematic review and meta-analysis aims to determine outcomes following aortic occlusion with the transthoracic clamp (TTC) versus endoaortic balloon occlusion (EABO) in patients undergoing minimally invasive mitral valve surgery. A subgroup analysis compares TTC to EABO with femoral cannulation separately from EABO with aortic cannulation. We searched Medline and Embase up to December 2018. Two people independently and in duplicate screened title and abstracts, full-text reports, extracted data and assessed the risk of bias using the Cochrane risk-of-bias tool for non-randomized studies. We identified 1564 reports from which 11 observational studies with 4181 participants met the inclusion criteria. We found no evidence of difference in the risk of postoperative death or cerebrovascular accident (CVA) between the 2 techniques. Evidence for a reduction in aortic dissection with TTC was found: 4 of 1590 for the TTC group vs 19 of 2492 for the EABO group [risk ratio 0.33, 95% confidence interval (CI) 0.12-0.93; P = 0.04]. There was no difference in aortic cross-clamp (AoX) time between TTC and EABO [mean difference (MD) -5.17 min, 95% CI -12.40 to 2.06; P = 0.16]. TTC was associated with a shorter AoX time compared to EABO with femoral cannulation (MD -9.26 min, 95% CI -17.00 to -1.52; P = 0.02). EABO with aortic cannulation was associated with a shorter AoX time compared to TTC (MD 7.77 min, 95% CI 3.29-12.26; P < 0.001). There was no difference in cardiopulmonary bypass (CPB) time between TTC and EABO with aortic cannulation (MD -4.98 min, 95% CI -14.41 to 4.45; P = 0.3). TTC was associated with a shorter CPB time compared to EABO with femoral cannulation (MD -10.08 min, 95% CI -19.93 to -0.22; P = 0.05). Despite a higher risk of aortic dissection with EABO, the rates of survival and cerebrovascular accident across the 2 techniques are similar in minimally invasive mitral valve surgery.