Myocardial Protection in Mitral Valve Surgery: Comparison Between Minimally Invasive Approach and Standard Sternotomy

Cardioplegia During Minimally Invasive Mitral Valve Surgery, a Team Approach

“…In their retrospective review, Lebon et al 1 examine the effect that switching from conventional open mitral valve surgery to a minimally invasive approach has on myocardial protection. The authors were unable to find a detrimental effect on myocardial function, with both groups having similar results clinically and nearly equivalent troponin enzyme release.…”

“…There are several approaches to myocardial protection in minimally invasive mitral valve surgery. 2 One of the earliest approaches, as employed by LeBon et al, 1 involves the use of a proprietary endoaortic balloon inserted via the femoral artery and advanced into the ascending aorta for occluding the aorta and delivering antegrade cardioplegia. Although this approach demonstrated initial feasibility, it is associated with the increased cost of the proprietary catheter, requires larger caliber femoral vessels and absence of aortic insufficiency, and may be associated with a higher risk of aortic dissection.…”

“…3 This usually is not an issue with minimally invasive mitral surgery because most patients have normal coronary arteries; however, some teams prefer to use retrograde cardioplegia when greater than mild aortic insufficiency is present (in the setting of severe aortic insufficiency, the goal would be median sternotomy to address the aortic valve simultaneously). The 3 main concerns with the use of retrograde cardioplegia are catheter displacement, as reported in one case by LeBon et al, 1 coronary sinus rupture, and inadequate protection of the right ventricle because right ventricular venous return is not directly connected to the coronary sinus. 4 Finally, a meta-analysis of trials suggested an increase in the rate of stroke may be associated with the use of endovascular antegrade cardioplegia, possibly related to the endoaortic balloon.…”

“…Two common solutions are custodial (HTK) and del Nido solution, 7 technically a hybrid solution. These strategies offer single or less frequent cardioplegic dosing, allowing prolonged uninterrupted surgery, and thus may reduce aortic cross clamp and cardiopulmonary bypass times and potentially the need for a retrograde catheter, as suggested by LeBon et al 1 Finally, the authors should be commended for discussing a patient who experienced catheter migration after cardiopulmonary bypass, which unfortunately went unnoticed. The result was cardiogenic shock, resulting ultimately in the death of the patient, which is a catastrophic complication in any patient coming for mitral repair.…”

“…Simple tools like checklists may facilitate communication and ensure consistency throughout the procedure. 8 The report by Lebon et al 1 is a reminder that, especially when learning new techniques, misadventure is not uncommon and hypervigilance is always necessary.…”