Predictors of Stroke After Minimally Invasive Mitral Valve Surgery Without the Cross-Clamp

Abstract

Minimally invasive mitral valve surgery (mini-MVS) with hypothermic fibrillatory arrest has been associated with an increased risk of stroke. We aim to investigate the incidence, predictors, and outcomes of stroke in a large cohort of patient who underwent clampless mini-MVS. Between January 2008 and June 2017, we performed 1247 mini-MVSs. The clinical, operative, and postoperative outcomes were analyzed. Univariable and multivariable regression analyses were used to identify predictors of postoperative stroke. The median follow-up was 5.2 years (interquartile range 2.6À7.5). The etiology of mitral valve (MV) disease was degenerative (60.4%, n = 753), functional (12.8%, n = 160), rheumatic (8.7%, n = 109), endocarditis (3.1%, n = 39), and reoperative MV surgery (14.9%, n = 186). The overall incidence of postoperative neurologic event was 2.5% (n = 31/1247). Univariable predictors of stroke were a higher Society of Thoracic Surgeons mortality risk (6.0 § 11.8% vs 3.3 § 5.2%, P < 0.001), advanced age, (69.6 § 12.1 years vs 63.0 § 13.6 years, P = 0.002), female gender (71.0% vs 46.3%, P = 0.007), and a history of a cerebrovascular accident (22.6% vs 8.7%, P = 0.008). Stroke patients had a higher 30-day mortality (22.6% vs 1.6%, P < 0.001) and a higher risk for long-term mortality (hazard ratio = 5.56, 95% confidence interval [CI] 3.2À9.6, P < 0.001). Advanced age (odds ratio [OR] 2.1; 95% CI 1.1À4.0; P = 0.02), female gender (OR 2.3; 95% CI 0.9À5.2; P = 0.05), and history of cerebrovascular accident (OR 3.1; 95% CI 0.98À10.1; P = 0.05) remained as independent predictors of stroke in the multivariable analysis. Our decade-long experience indicates that clampless mini-MVS is associated with a low incidence of postoperative stroke, and that the predictors of stroke are not specific to this approach.Semin Thoracic Surg 32:47-56 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Intimal aortic atherosclerosis in cardiac surgery: surgical strategies to prevent embolic stroke

“…Despite being a safe and frequently used location in selected patients undergoing minimally invasive surgery, retrograde perfusion from the femoral artery has been associated with increased stroke rates in patients with aortic atherosclerosis [ 37 , 38 ]. This association was not observed in studies on minimally invasive mitral valve surgery, when femoral cannulation was changed to aortic or axillary cannulation in patients with severe aortic atherosclerosis [ 39 , 40 ]. Retrograde perfusion thus seems to be safe as long as these patients are excluded.…”

Minimally invasive tricuspid valve surgery

“…For the past two decades, MICS was reported to be associated with a significantly increased risk of CVA compared to standard sternotomy (47). This was always thought to be caused by performing surgery with retrograde cardiopulmonary bypass so, many centres started to shift towards antegrade cardiopulmonary bypass using axillary artery cannulation or direct aortic cannulation (48).…”

Case of postoperative mitral and tricuspid valve repair with large vessel occlusion ischaemic stroke: successfully treated with mechanical thrombectomy extracting subocclusive thrombus containing foreign material

“…Several factors can increase the risk of foreign material embolism during mitral and tricuspid valve repair surgery. For example, older patients, patients with pre-existing cardiovascular disease and those with a history of stroke are at an increased risk of developing foreign material embolism during or after the surgery 8 9. Moreover, the type of valve repair surgery being performed can also impact the risk of foreign material embolism.…”