Abstract
BackgroundRecently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.MethodsTrans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.ResultsA total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001).ConclusionThere is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.Trial registry numberclinicaltrials.gov, NCT02697786 14.
Highlights
Degenerative aortic valve stenosis is the most common valvular cardiac disease in developed countries and affects more than 4% of North American and European citizens [1, 2]
The main finding of our study is that MT approach for surgical aortic valve replacement (AVR) is comparable to MS access in regards to microembolic signals (MES) load, indicating that MT represents a safe and efficient minimally invasive surgical approach for AVR, enabling a feasible surgical valve procedure through the second intercostal space without any division of the sternum
We have found an independent relationship between postsurgical proinflammatory interleukin 6 (IL-6) levels and MES counts during surgery, but IL-6 levels were independently associated with surgery length
Summary
Degenerative aortic valve stenosis is the most common valvular cardiac disease in developed countries and affects more than 4% of North American and European citizens [1, 2]. Surgical aortic valve replacement (AVR) with the use of cardiopulmonary bypass (CPB) is one of several treatment options. Despite improvements in surgical techniques and postoperative medical care, neurological impairment remains a major complication after cardiac surgery [3]. Mechanisms of brain injury after cardiac surgery are related to impaired cerebral blood flow, hyperthermia, atrial fibrillation, genetic predisposition, and systemic inflammatory response (SIRS) associated with CPB [5]. Whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation
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