Article Abstract

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

Authors: Johan van der Merwe, Frank Van Praet, Yvette Vermeulen, Filip Casselman


Background: This studyreports the intra-operative complications, reasons for sternotomy conversion(SC) and the important pitfalls associated with minimally invasiveatrioventricular valve surgery by endo-aortic balloon occlusion (MIAS) that mayassist emerging centres in developing safe, efficient and sustainable programs.
Methods: Peri-operative data for patientsoperated over the last 5 years was obtained from a prospective database. Intotal, 511 consecutive patients with isolated atrioventricular valve (AVV)disease underwent MIAS (mean age 65.6±13.7 years, 46.8% female, 21.7% redo-cardiacsurgery, 5.7% previous MIAS, 2.9% isolated AVV endocarditis, 13.9% body massindex above 30 kg/m2) at our institution between May 1st2013 and April 30th 2018. The mean EuroSCORE II was 5.9%±9.4% andrheumatic AVV disease was diagnosed in 32 (6.3%) patients. Other surgicalindications included chronic atrial fibrillation (n=142, 27.8%) and leftventricle outflow tract (LVOT) obstruction in conjunction with mitral (MV) ortricuspid valve (TV) disease (n=7, 1.4%).
Results: Procedures performed included 122 AVVreplacements (MV =105, TV =17) and 478 AVV repairs (MV=383, TV=95) in isolationor combination. Concomitant procedures included cryo-ablation (n=142, 27.8%)and LVOT resection (n=7, 1.4%). Intra-operative complications that required SCoccurred 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 mortalityfor 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: Minimallyinvasive surgical approaches for AVV disease are increasingly being recognizedas the “gold-standard” in the context of rapidly expanding trans-catheter technologyand increasing patient expectations. In an era of strict quality control andclinical governance, emerging MIAS centres need to be aware of the possibleintra-operative complications and potential pitfalls to apply effective riskreduction strategies that encourage safe and sustainable programs.