Complications and pitfalls in minimally invasive atrioventricular valve surgery utilizing endo-aortic balloon occlusion technology

Background: This study reports the intra-operative complications, reasons for sternotomy conversion (SC) and the important pitfalls associated with minimally invasive atrioventricular valve surgery by endo-aortic balloon occlusion (MIAS) that may assist emerging centres in developing safe, efficient and sustainable programs. Methods: Peri-operative data for patients operated over the last 5 years was obtained from a prospective database. In total, 511 consecutive patients with isolated atrioventricular valve (AVV) disease underwent MIAS (mean age 65.6±13.7 years, 46.8% female, 21.7% redo-cardiac surgery, 5.7% previous MIAS, 2.9% isolated AVV endocarditis, 13.9% body mass index above 30 kg/m 2 ) at our institution between May 1 st 2013 and April 30 th 2018. The mean EuroSCORE II was 5.9%±9.4% and rheumatic AVV disease was diagnosed in 32 (6.3%) patients. Other surgical indications included chronic atrial fibrillation (n=142, 27.8%) and left ventricle outflow tract (LVOT) obstruction in conjunction with mitral (MV) or tricuspid valve (TV) disease (n=7, 1.4%). Results: Procedures performed included 122 AVV replacements (MV =105, TV =17) and 478 AVV repairs (MV=383, TV=95) in isolation or combination. Concomitant procedures included cryo-ablation (n=142, 27.8%) and LVOT resection (n=7, 1.4%). Intra-operative complications that required SC occurred in 16 (3.1%) patients and in 13 of 399 (3.3%) isolated MV procedures. Reasons for SC included lung adhesions (n=5, 1.0%), cannulation difficulty (n=3, 0.6%), atrioventricular dehiscence (n=1, 0.2%) and bleeding (n=4, 0.8%). Other peri-operative complications included neurological deficit (n=2, 0.4%) and myocardial infarction (n=1, 0.2%). The intra-operative and 30-day mortality for the 5-year MIAS series (n=511) was 0.4% (n=2) and 4.5% (n=23) respectively. Complications that resulted in SC (n=16) were associated with a 25% (n=4) 30-day mortality. Conclusions: Minimally invasive surgical approaches for AVV disease are increasingly being recognized as the “gold-standard” in the context of rapidly expanding trans-catheter technology and increasing patient expectations. In an era of strict quality control and clinical governance, emerging MIAS centres need to be aware of the possible intra-operative complications and potential pitfalls to apply effective risk reduction strategies that encourage safe and sustainable programs.