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Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Aortic cross-clamp time correlates with mortality in the mini-mitral international registry
Torsten Doenst1, Paolo Berretta2, Nikolaos Bonaros3
1Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany.
Objectives:
Minimally invasive access has become the preferred choice in mitral and/or tricuspid valve surgery. Reported outcomes are at least similar to classic sternotomy although aortic cross-clamp times are usually longer.
Methods:
We analysed the largest registry of mitral and/or tricuspid valve surgery patients (mini-mitral international registry (MMIR)) for the relationship between aortic cross-clamp times, mortality and other outcomes. From 2015 to 2021, 7513 consecutive patients underwent mini-mitral and/or tricuspid valve surgery in 17 international Heart-Valve-Centres. Data were collected according to Mitral Valve Academic Research Consortium (MVARC) definitions and 6878 patients with 1 cross-clamp period were analysed. Uni- and multivariable regression analyses were used to assess outcomes in relation to aortic cross-clamp times.
Results:
Median age was 65 years (57% male). Median EuroSCORE II was 1.3% (Inpatient Quality Reporting (IQR): 0.80-2.63). Minimally invasive access was either by direct vision (28%), video-assisted (41%) or totally endoscopic/robotic (31%). Femoral cannulation was used in 93%. Three quarters were repairs with 17% additional tricuspid valve surgery and 19% Atrial Fibrillation (AF)-ablation. Cardiopulmonary bypass and cross-clamp times were 135 min (IQR: 107-173) and 85 min (IQR: 64-111), respectively. Postoperative events were death (1.6%), stroke (1.2%), bleeding requiring revision (6%), low cardiac output syndrome (3.5%) and acute kidney injury (6.2%, mainly stage I). Statistical analyses identified significant associations between cross-clamp time and mortality, low cardiac output syndrome and acute kidney injury (all P < 0.001). Age, low ejection fraction and emergent surgery were risk factors, but variables of 'increased complexity' (redo, endocarditis, concomitant procedures) were not.
Conclusions:
Aortic cross-clamp time is associated with mortality as well as postoperatively impaired cardiac and renal function. Thus, implementing measures to reduce cross-clamp time may improve outcomes.
Insights
Minimally invasive mitral and tricuspid valve surgery is preferred, but longer aortic cross-clamp times are linked to increased mortality and organ dysfunction. Reducing cross-clamp duration is key to improving patient outcomes in these procedures.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Techniques
- Transcatheter Valve Interventions
Background:
- Minimally invasive approaches are now standard for mitral and/or tricuspid valve surgery.
- While outcomes are comparable to sternotomy, minimally invasive procedures often involve longer aortic cross-clamp times.
Purpose of the Study:
- To investigate the relationship between aortic cross-clamp duration and patient outcomes in minimally invasive mitral and/or tricuspid valve surgery.
- To analyze data from the largest international registry for these procedures.
Main Methods:
- Analysis of 6878 patients from the mini-mitral international registry (MMIR) between 2015 and 2021.
- Utilized Mitral Valve Academic Research Consortium (MVARC) definitions for data collection.
- Employed uni- and multivariable regression analyses to assess the impact of aortic cross-clamp times on outcomes.
Main Results:
- A significant association was found between longer aortic cross-clamp times and increased mortality (1.6%), low cardiac output syndrome (3.5%), and acute kidney injury (6.2%).
- Other risk factors included older age, low ejection fraction, and emergent surgery.
- Increased surgical complexity (redo surgery, endocarditis, concomitant procedures) did not show a significant association with adverse outcomes in relation to cross-clamp time.
Conclusions:
- Aortic cross-clamp time is a critical factor associated with mortality and postoperative cardiac and renal dysfunction.
- Strategies aimed at reducing aortic cross-clamp duration are essential for enhancing patient outcomes in minimally invasive valve surgery.
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