Central venous cannulation and antegrade arterial perfusion for minimally invasive aortic valve surgery: Return to the basics

Abstract

We read with great interest the letter from Lu and colleagues [1]and we wanted to thank the authors for their constructive comments.Their manuscript addresses some issues that may be resumed in thefollowing points:a) The potential interest of performing minimally invasive aorticvalve replacement and more precisely through an anterior rightminithoracotomy approach.As mentioned by the authors, there is growing evidence in theliteratureoftheinterestofsuchsurgicalapproach.Indeed,Gilmanovand colleagues [2] showed with a propensity scored analysis thatminimally invasive aortic replacement was a reliable and a safetechniquewithbetterpostoperativeoutcomes,thanfullsternotomy,withrespecttoassistedventilationduration,bloodtransfusionsandpostoperative atrial fibrillation.On the other hand, regarding the choice of minimal invasiveaortic valve replacement between ministernotomy and rightminithoracotomy, it would seem that the latter has a slightadvantage in the postoperative period with patients having anearlier rehabilitation[3,4].At the light of these evidences we agree with Lu and colleaguesthat one may state that right minithoracotomy is a valuable andreliable option for aortic valve replacement.b) The necessityofperforming aroutine contrast-enhancedCTscan.As stated in our article [5], we totally agree with this attitude.However,onemustkeepinmindthatthisexammayshowcalcifiedfemoral arteries, thus contraindicating a patient for minimallyinvasive surgery, while an axillary perfusion approach could makehim eligible for this kind of surgery. Moreover, we may add thatthis exam plays a key role in studying patients' eligibility for theprocedure. We think that the right anterior minithoracotomyapproach is not feasible in all patients and that anatomicallandmarks in the CT scan, as shown by Glauber and colleagues [6],should guide the surgeon's choices.c) The interest of establishing CPB by the femoral vessels.ThiswastheoriginaltechniquedescribedbyCosgroveandSabik[7].The authors established CPB after surgical cut-down of the groinand leaved untouched the surgical field at the level of theminithoracotomy. Based on their experience of minimally invasivesurgery, including patients with mitral and aortic pathology,Lu and colleagues find that this perfusion technique is reliableand should be performed in all patients. We do believe that such astatement should be nuanced.In fact, we must have a different surgical strategy for minimallyinvasive surgery in patients with mitral and aortic pathology. Indeed,aortic valvular patients cannot be compared with patients havingminimally invasive mitral repair or replacement and in which femoralCPB is the gold standard. As a matter of fact, in our Caucasian cohort,patientswithaorticvalvestenosisareolder,withmorecalcifiedarteriesand frequent peripheral arterial disease which makes them unsuitablefor retrograde arterial femoral cannulation and perfusion. In this caseantegrade perfusion reduces the risks of retrograde aortic dissectionand cerebral microembolization. Lastly, the wound healing of thegroin may be very difficult, especially in obese or diabetic patients.Knowing these risks, Glauber and colleagues[6] modified theirtechnique of perfusion for minimally invasive aortic valve replace-ment in 2011. CPB was established between a percutaneous femoralvenous cannulation and a direct aortic cannulation through theminithoracotomy. This slightly reduced the surgical field, yet withoutany relevant surgical discomfort. However, this technique demands a