Right Mini-thoracotomy Mitral Valve Surgery

erfusion strategies and aortic clamping techniques for right mini-thoracotomy mitral valve surgery (MVS) have evolved over time; since the first video-assisted mitral valve (MV) repair performed by Alain Carpentier in 1996, new technologies and operation-specific methods have been introduced. 1 Concomitantly, several centers all over the world have adopted this approach and have developed experience in this challenging field.Excellent short-and long-term results have been reported: right mini-thoracotomy MVS has established early and long-term mortality and valve function results comparable with those of the conventional sternotomy approach, as well as less pain, less blood loss, less transfusions, and re-explorations for bleeding, a trend toward shorter hospital stay, faster recovery, less use of rehabilitation resources, and overall healthcare savings.2,3 Despite these encouraging reports, broad adoption of the right mini-thoracotomy approach is still limited.A report from The Society of Thoracic Surgeons indicates that this approach is performed only in 20% of the overall isolated MV procedures. 2 This limited compliance might be explain by the fact that the transition from the traditional approach to the right mini-thoracotomy approach requires demanding training and a challenging learning curve for surgeons, anesthesiologists, perfusionists, and scrub nurses and that investments in video assistance platforms, surgical instruments, and perfusion cannulas are required.4 Moreover, there is still debate regarding the rate of neurological events associated with the right mini-thoracotomy approach and regarding the role of perfusion strategies and clamping techniques in the occurrence of this complication.5,6 Several studies have suggested that retrograde arterial perfusion (RAP), particularly in patients with severe peripheral vascular disease, could be related to the potential drawback of neurological complications in right mini-thoracotomy MVS.5,6 Grossi et al. 5 claimed that the only significant risk factor for neurological events during right mini-thoracotomy MV repair was the use of RAP in patients with severe peripheral vascular disease.Comparable results were reported also by Murzi et al. 6 in a series of 1280 minimal access MVS: the use of RAP contributed to a 4.28-fold increase in the risk of stroke.The different aortic clamping techniques have also been extensively reviewed.The standard set-up uses RAP through the femoral artery and endoaortic balloon clamping (EAC) or transthoracic aortic clamping (TTC).In the EAC, aortic occlusion and cardioplegia delivery are obtained through an endoluminar balloon catheter (Intraclude, Edwards Lifesciences Corp., Irvine, CA USA); in the TTC, aortic occlusion is obtained through a transthoracic direct clamping and a separate line into the ascending aorta is used for cardioplegia delivering.The EAC setting has reported good results particularly in the subgroup of patients with previous cardiac operations.7 Concerns regarding neurological events within this setting are mainly related to the use of RAP and retrograde balloon manipulation in case of aortoiliac atheromatous disease.3,6,8