Iatrogenic aortic dissection in minimally invasive cardiac surgery for atrioventricular valves and atrial structures

OBJECTIVES: In the last decades, minimally invasive cardiac surgery has emerged as an alternative approach to conventional median sternotomy. However, some reports state an increased risk of iatrogenic acute aortic dissection. Evidence remains limited regarding preoperative diagnostics for risk reduction and the appropriate adjustment of surgical procedures if acute aortic dissection is detected intraoperatively. METHODS: In this retrospective single-centre observational study, we analysed 1065 patients who underwent minimally invasive cardiac surgery via right anterolateral thoracotomy for atrioventricular valves and atrial structures with femoral cannulation for cardiopulmonary bypass from August 2009 to June 2021. Occurrence of iatrogenic acute aortic dissection was evaluated, along with patient profiles and the primary composite outcome of major adverse cardiovascular events (non-fatal stroke, myocardial infarction or cardiovascular death). An optimal perioperative strategy was subsequently described. RESULTS: Intraoperative iatrogenic acute aortic dissection was observed in 8 patients (0.75%). It was identified at the start of cardiopulmonary bypass in 4 patients (50.0%). All patients underwent conversion to full sternotomy; 7 patients underwent additional aortic surgery with circulatory arrest thereafter. In-hospital mortality was 37.5% (n = 3), including 1 intraoperative death. Non-fatal stroke was observed in 12.5% (n = 1). A preoperative computed tomography scan was missing in 3 patients with aortic calcification (n = 1) and hostile peripheral arteries (n = 2). CONCLUSIONS: Intraoperative aortic dissection in minimally invasive cardiac surgery remains a rare complication. Frequent major adverse cardiovascular events highlight the importance of preoperative imaging based procedure planning. Intraoperatively, early diagnosis with standardized monitoring and time- and location-specific surgical adaptations might increase safety and outcomes.