Download PDF
Int J Angiol
DOI: 10.1055/a-2572-1060
Original Article

Comparison of Endoaortic Balloon Occlusion and Transthoracic Aortic Clamp for Minimally Invasive Cardiac Surgery: Systematic Review and Meta-analysis

Noritsugu Naito 
1   Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
,
Hisato Takagi
1   Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Objective

This meta-analysis aimed to compare short-term outcomes in patients undergoing minimally invasive cardiac surgery (MICS) using endoaortic balloon (EAB) and transthoracic aortic clamp (TAC) techniques.

Materials and Methods

A comprehensive search of relevant databases was conducted through July 2024. Pooled results were calculated, and subgroup analyses of studies published during early and late eras were performed. Additionally, a meta-regression analysis based on the year of publication was conducted to assess potential influences on outcomes.

Results

The systematic review identified 17 non-randomized studies encompassing a total of 8,253 patients. In terms of intraoperative outcomes, no significant differences were observed in operation duration, aortic cross-clamp time, cardiopulmonary bypass time, or rates of sternotomy conversion and iatrogenic aortic dissection. However, subgroup analysis of early-era studies demonstrated significantly longer operation times in the EAB cohort (p = 0.03). Meta-regression analysis indicated that the standardized mean differences in cardiopulmonary bypass time between the two groups decreased in favor of EAB as publication years progressed (p = 0.01). For postoperative outcomes, no significant differences were found in postoperative stroke rate, the rate of reoperation for bleeding, or length of hospital stay. However, the EAB group had significantly lower rates of postoperative atrial fibrillation (OR = 0.82 [0.70–0.95], p < 0.01) and short-term mortality (OR = 0.60 [0.39–0.92], p = 0.04).

Conclusion

This meta-analysis demonstrated that EAB is associated with perioperative outcomes comparable to TAC in select patients. The cumulative experience and evolution of techniques may have contributed to improved outcomes with EAB over time.

Keywords

meta-analysis - perioperative outcomes - postoperative complications - minimally invasive cardiac surgery - aortic cross clamp - endoaortic clamp - cardiopulmonary bypass


Publication History

Article published online:
21 April 2025

© 2025. International College of Angiology. This article is published by Thieme.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Mori M, Parsons N, Krane M. et al. Robotic mitral valve repair for degenerative mitral regurgitation. Ann Thorac Surg 2024; 117 (01) 96-104
    PubMedSearch in Google Scholar
  • 2 Sheetz KH, Claflin J, Dimick JB. Trends in the adoption of robotic surgery for common surgical procedures. JAMA Netw Open 2020; 3 (01) e1918911
    CrossrefPubMedSearch in Google Scholar
  • 3 Loulmet DF, Grossi EA. Two decades of experience with robotic mitral valve repair: what have we learned?. JTCVS Tech 2024; 24: 76-81
    PubMedSearch in Google Scholar
  • 4 Franke UFW, Huether F, Ghinescu M. et al. Robotically assisted mitral valve surgery—experience during the restart of a robotic program in Germany. Ann Cardiothorac Surg 2022; 11 (06) 596-604
    PubMedSearch in Google Scholar
  • 5 Modi P, Hassan A, Chitwood Jr WR. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2008; 34 (05) 943-952
    PubMedSearch in Google Scholar
  • 6 Algarni KD, Suri RM, Schaff H. Minimally invasive mitral valve surgery: does it make a difference?. Trends Cardiovasc Med 2015; 25 (05) 456-465
    PubMedSearch in Google Scholar
  • 7 Malvindi PG, Margari V, Mastro F. et al. External aortic cross-clamping and endoaortic balloon occlusion in minimally invasive mitral valve surgery. Ann Cardiothorac Surg 2018; 7 (06) 748-754
    PubMedSearch in Google Scholar
  • 8 Yost CC, Rosen JL, Mandel JL. et al. Endoaortic balloon occlusion versus transthoracic cross-clamp for totally endoscopic robotic mitral valve surgery: a retrospective cohort study. J Robot Surg 2023; 17 (05) 2305-2313
    PubMedSearch in Google Scholar
  • 9 Barbero C, Rinaldi M, Pocar M. et al. Endo-aortic vs. trans-thoracic clamping in right mini-thoracotomy mitral valve surgery: outcome on myocardial protection. Front Cardiovasc Med 2021; 8: 719687
    PubMedSearch in Google Scholar
  • 10 Rival PM, Moore THM, McAleenan A. et al. Transthoracic clamp versus endoaortic balloon occlusion in minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2019; 56 (04) 643-653
    PubMedSearch in Google Scholar
  • 11 Khan H, Hadjittofi C, Uzzaman M. et al. External aortic clamping versus endoaortic balloon occlusion in minimally invasive cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 27 (02) 208-214
    PubMedSearch in Google Scholar
  • 12 Ailawadi G, Agnihotri AK, Mehall JR. et al. Minimally invasive mitral valve surgery I: patient selection, evaluation, and planning. Innovations (Phila) 2016; 11 (04) 243-250
    PubMedSearch in Google Scholar
  • 13 Pisano C, Farinaccio A, Altieri C. et al. Imaging and monitoring in minimally invasive valve surgery using an intra-aortic occlusion device: a single center experience. J Thorac Dis 2021; 13 (02) 1011-1019
    PubMedSearch in Google Scholar
  • 14 Casselman F, Aramendi J, Bentala M. et al. Endoaortic clamping does not increase the risk of stroke in minimal access mitral valve surgery: a multicenter experience. Ann Thorac Surg 2015; 100 (04) 1334-1339
    PubMedSearch in Google Scholar
  • 15 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
    CrossrefPubMedSearch in Google Scholar
  • 16 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315 (7109) 629-634
    CrossrefPubMedSearch in Google Scholar
  • 17 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
    CrossrefPubMedSearch in Google Scholar
  • 18 Ergi DG, Rowse PG, Daly RC. et al. Single-center prospective study of cross-clamp vs balloon occlusion in robotic mitral surgery. Ann Thorac Surg 2024; 118 (02) 412-419
    PubMedSearch in Google Scholar
  • 19 Balkhy HH, Grossi EA, Kiaii B. et al. A retrospective evaluation of endo-aortic balloon occlusion compared to external clamping in minimally invasive mitral valve surgery. Semin Thorac Cardiovasc Surg 2024; 36 (01) 27-36
    PubMedSearch in Google Scholar
  • 20 Grazioli V, Giroletti L, Graniero A. et al. Comparative myocardial protection of endoaortic balloon versus external clamp in minimally invasive mitral valve surgery. J Cardiovasc Med (Hagerstown) 2023; 24 (03) 184-190
    PubMedSearch in Google Scholar
  • 21 Balkhy HH, Grossi EA, Kiaii B. et al. Cost and clinical outcomes evaluation between the endoaortic balloon and external aortic clamp in cardiac surgery. Innovations (Phila) 2023; 18 (04) 338-345
    PubMedSearch in Google Scholar
  • 22 Cetinkaya A, Ebraheem E, Bramlage K. et al. Long-term results of endoclamping in patients undergoing minimally invasive mitral valve surgery where external aortic clamping cannot be used—a propensity matched analysis. J Cardiothorac Surg 2020; 15 (01) 313
    PubMedSearch in Google Scholar
  • 23 Barbero C, Krakor R, Bentala M. et al. Comparison of endoaortic and transthoracic aortic clamping in less-invasive mitral valve surgery. Ann Thorac Surg 2018; 105 (03) 794-798
    PubMedSearch in Google Scholar
  • 24 Bentala M, Heuts S, Vos R. et al. Comparing the endo-aortic balloon and the external aortic clamp in minimally invasive mitral valve surgery. Interact Cardiovasc Thorac Surg 2015; 21 (03) 359-365
    PubMedSearch in Google Scholar
  • 25 Atluri P, Goldstone AB, Fox J, Szeto WY, Hargrove WC. Port access cardiac operations can be safely performed with either endoaortic balloon or Chitwood clamp. Ann Thorac Surg 2014; 98 (05) 1579-1583 , discussion 1583–1584
    PubMedSearch in Google Scholar
  • 26 Mazine A, Pellerin M, Lebon JS, Dionne PO, Jeanmart H, Bouchard D. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes. Ann Thorac Surg 2013; 96 (06) 2116-2122
    PubMedSearch in Google Scholar
  • 27 Loforte A, Luzi G, Montalto A. et al. Video-assisted minimally invasive mitral valve surgery: external aortic clamp versus endoclamp techniques. Innovations (Phila) 2010; 5 (06) 413-418
    PubMedSearch in Google Scholar
  • 28 Glower DD, Desai B. Transaortic endoclamp for mitral valve operation through right minithoracotomy in 369 patients. Innovations (Phila) 2010; 5 (06) 394-399
    PubMedSearch in Google Scholar
  • 29 Ius F, Mazzaro E, Tursi V. et al. Clinical results of minimally invasive mitral valve surgery: endoaortic clamp versus external aortic clamp techniques. Innovations (Phila) 2009; 4 (06) 311-318
    PubMedSearch in Google Scholar
  • 30 Maselli D, Pizio R, Borelli G, Musumeci F. Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli. Interact Cardiovasc Thorac Surg 2006; 5 (02) 183-186
    PubMedSearch in Google Scholar
  • 31 Aybek T, Dogan S, Wimmer-Greinecker G, Westphal K, Mortiz A. The micro-mitral operation comparing the Port-Access technique and the transthoracic clamp technique. J Card Surg 2000; 15 (01) 76-81
    PubMedSearch in Google Scholar
  • 32 Patel NC, Macoskey AR. Complications and their management in robotic mitral valve surgery from the surgical assistant's perspective. Ann Cardiothorac Surg 2022; 11 (05) 510-524
    PubMedSearch in Google Scholar
  • 33 Loulmet DF, Ranganath NK, Neragi-Miandoab S. et al. Advanced experience allows robotic mitral valve repair in the presence of extensive mitral annular calcification. J Thorac Cardiovasc Surg 2021; 161 (01) 80-88
    PubMedSearch in Google Scholar
  • 34 Rosu C, Bouchard D, Pellerin M, Lebon JS, Jeanmart H. Preoperative vascular imaging for predicting intraoperative modification of peripheral arterial cannulation during minimally invasive mitral valve surgery. Innovations (Phila) 2015; 10 (01) 39-43
    PubMedSearch in Google Scholar
  • 35 Falk V, Cheng DC, Martin J. et al. Minimally invasive versus open mitral valve surgery: a consensus statement of the international society of minimally invasive coronary surgery (ISMICS) 2010. Innovations (Phila) 2011; 6 (02) 66-76
    PubMedSearch in Google Scholar