Antegrade versus Retrograde Arterial Perfusion in Minimally Invasive Mitral Valve Surgery: Axillary versus Femoral

Objectives: Femoral artery perfusion represents a standard cannulation approach in minimally invasive mitral valve surgery, despite well-known limitations of the retrograde aortic perfusion. Antegrade arterial flow through the axillary artery has theoretical advantages as compared to the retrograde femoral approach, especially in the setting of severe atherosclerotic aortic disease. We aimed to compare the postoperative outcomes of axillary artery perfusion vs. retrograde femoral perfusion in the minimally invasive mitral valve surgery setting.

Methods: We systematically analyzed the outcomes of 50 consecutive patients who underwent minimally-invasive mitral valve surgery between 2016 and 2019 using the arterial cannulation of right axillary artery (Group A) due to severe aortic arteriosclerosis. Perioperative outcomes of the study group were compared with a historical control group of retrograde femoral perfusion (Group F) which was adjusted for age and gender (n = 50) according to the propensity score matching. Primary endpoint of the study was in-hospital mortality and perioperative cerebrovascular events.

Results: Perioperative risk score values were significantly higher in group A compared to Group F (Euroscore II: 3.99 ± 2.57 vs. 1.67 ± 1.58; p = 0.001; STS score: 2.19 ± 1.49 vs. 1.31 ± 0.64; p = 0.023). Cardiopulmonary bypass time (group A: 172 ± 46; group F: 178 ± 51 minutes; p = 0.627) and duration of surgery (group A: 260 ± 65; group F: 257 ± 69 minutes; p = 0.870) was comparable in both groups. However, aortic cross clamp time was significantly shorter in the group A as compared to group F (86 ± 20 vs. 111 ± 29 minutes, < p < 0.001). There was no perioperative stroke in both study groups. In-hospital mortality was comparable in both groups (p = 0.289). In group A, one patient required median sternotomy and central aortic repair due to intraoperative aortic dissection. No further cardiovascular events occurred in the Group A, despite significantly increased perioperative risk profile.

Conclusion: Right axillary artery perfusion is a safe and reproducible technique in elderly patients with the systemic atherosclerosis who undergo minimally invasive mitral valve surgery. Given the appropriate institutional expertise in minimally invasive mitral valve surgery, high-risk patients with severe arteriosclerosis can be safely treated via the minimally invasive approach using antegrade arterial perfusion.