As MICS has evolved, so too have the strategies and approaches to CPB access. Early descriptions of MICS involve a parasternotomy incision with direct aortic, direct SVC, and percutaneous IVC access6 or ministernotomy with femoral artery, direct SVC, and percutaneous IVC cannulation.7 Shortly thereafter, the port-access system was developed and was widely adopted, which involved obtaining arterial access via the femoral artery and deploying a balloon to achieve endovascular aortic occlusion.8 Subsequent problems with peripheral vascular complications, aortic dissections, and strokes led to a decline in its use.
Over our 10-year experience with MICS, we have also seen a progression in our techniques. Early descriptions in the literature of MICS techniques predominantly involved peripheral arterial cannulation through the femoral artery. As we began our minimally invasive practice, our earliest operations involved similar methods, with femoral artery access and endoaortic balloon occlusion. With increased institutional experience and with the growing body of evidence that peripheral cannulation was associated with higher incidences of stroke and vascular complications,9 we developed our central cannulation technique that allowed preferential cannulation of the aorta. To minimize the risk of aortic dissection, we also replaced the endovascular balloon with a percutaneous transaxillary aortic XC that allowed for direct aortic occlusion.10,11
Similarly, our original cannulation techniques involved percutaneous bicaval venous drainage, with SVC access through the RIJ vein and IVC access from the right femoral vein. Drawbacks to this technique included location of the RIJ cannula outside our sterile operative field by anesthesia. In addition, we found the cannula to be cumbersome, and it created a large defect in the vein. We began using direct SVC and percutaneous femoral vein access. With the development of the dual-stage femoral vein cannula, we have changed our practice to achieve bicaval venous drainage through a single percutaneous venous access site. However, in cases where right atriotomy is necessary, we continue to use direct SVC and percutaneous IVC drainage. Adequacy of venous drainage was checked with central venous pressure monitoring and transesophageal echocardiography.
In assessing patients for appropriate cannulation techniques, numerous factors deserve consideration. When performing femoral artery cannulation, we ruled out patients with aortoiliac disease and small femoral arteries. Extensive aortic atherosclerosis was a contraindication for central aortic cannulation. Central cannulation was more challenging in patients with CHF and reoperative sternotomies, and as such, they were more commonly approached with peripheral arterial cannulation. Patients with IVC filters were not candidates for percutaneous venous cannulation via the femoral vein.
Minimally invasive cardiac surgery has been shown in numerous studies to have comparable mortality rates when compared with standard median sternotomy.12–16 Less invasive techniques have also been shown to result in decreased length of hospital stay, reduced postoperative pain, improved patient satisfaction, faster return to daily physical activities, and higher quality of life.7,13,15,17–21 However, serious concerns have been raised regarding increased morbidity associated with MICS. In particular, a greater number of strokes were seen in MICS patients in an analysis of the Society of Thoracic Surgeons Database.9 A meta-analysis of six papers did not find a similar increase in the number of neurological events.11 A propensity analysis comparing minimally invasive and median sternotomy mitral valve surgeries at our institution also did not find any increase in the relative number of strokes,15 a difference we attribute, in part, to our methods of central aortic cannulation, meticulous deairing, and direct aortic occlusion. The stroke rate of less than 1% in this study population reinforces that finding.
Limitations to our study include the retrospective nature of the analysis and the lack of patient-matched controls for different cannulation techniques across time periods. In addition, our information on complications was limited to those that occurred during the initial hospitalization. We did not have information on long-term neurological or functional status. We also attempted to examine differences in outcomes over time as our techniques changed, but the small number of events made adequate analysis impossible. In addition, given the low complication rate, we did not have the power to adequately examine risk factors associated with individual complications.
In our series, the mean CPB and aortic XC times of 122 and 75 minutes, respectively, demonstrate that despite a learning curve associated with new techniques, our cannulation strategies are feasible with reasonable operative times. Our stroke rate and the 9.1% in-hospital complication rate are acceptably low and comparable with those in large published reports.9 Multivariate logistic regression showed an increased risk of postoperative complication with peripheral arterial cannulation when compared with central aortic cannulation. In addition, increased age and preoperative hepatic failure were found to increase risk of complications. Not surprisingly, postoperative stroke was more common in patients with aortic atherosclerosis and a preoperative history of stroke. Operative mortality was 2.0%, with increased age and previous cardiac surgery as predictive risk factors. Long-term outcomes demonstrated 82% survival at 10 years, with previous cardiac surgery, increased age, and CHF as risk factors for death, according to Cox proportional hazard analysis.
Over 10 years, our cannulation strategy for MICS has evolved to favor central aortic over femoral artery cannulation, percutaneous femoral dual-stage bicaval venous drainage over percutaneous neck access, and direct transaxillary clamping over endoaortic balloon occlusion of the aorta. In our experience, this approach has resulted in low complication rates and a reliable platform for a variety of MICS procedures.
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This retrospective, observational study examined the evolution of cannulation techniques for minimally invasive cardiac surgery at a busy academic center. The authors examined more than 1000 cases during a 10-year period. Their cannulation techniques evolved over this time to favor central over femoral arterial cannulation and percutaneous dual-stage femoral venous drainage over percutaneous neck access. They also moved from endoaortic balloon clamping of the aorta toward direct clamping via a transaxillary approach. They suggested that this evolution has played a role in their low complication rate and excellent outcomes.
This is an important contribution to the literature from one of the pioneering groups in minimally invasive cardiac surgery. It is noteworthy for the number of patients and the length of their experience. However, the study suffers from its nonrandomized nature and its inadequate power to adequately discriminate and compare the complication rates of the different cannulation strategies.
Keywords:Copyright © 2012 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Cannulation; Minimally invasive cardiac surgery; Techniques; Aortic occlusion