• Michele Murzi, Alfredo G Cerillo, Tommaso Gasbarri, Rafik Margaryan, Enkel Kallushi, Pierandrea Farneti, and Marco Solinas.
• Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
• Interact Cardiovasc Thorac Surg. 2017 Mar 1; 24 (3): 363-368.

ObjectivesThe aim of the present study was to evaluate the impact of a retrograde arterial perfusion (RAP) strategy versus an antegrade arterial perfusion (AAP) strategy in a consecutive, large cohort of patients who underwent minimally invasive mitral valve surgery with transthoracic aortic clamping through a right minithoracotomy.MethodsBetween 2003 and 2015, 1632 consecutive patients underwent first-time minimally invasive mitral valve surgery with transthoracic aortic clamping at our institution; 141 (8.6%) of these patients received retrograde perfusion with femoral artery cannulation, whereas 1421 (91.4%) received antegrade perfusion with ascending aorta cannulation. Logistic regression was used to evaluate outcomes and risk factors for death and stroke between groups.ResultsThe overall frequency of 30-day mortality was 0.7% (13/1632) and was similar between groups (retrograde arterial perfusion RAP 0.7% vs AAP 0.8%; P  = 0.903). The overall postoperative stroke rate was 1.3% (22/1632). The stroke rate was significantly higher in patients receiving retrograde perfusion (3.5% vs 1.1%; P  = 0.005). Risk factors for death were advanced age (odds ratio (OR) = 1.3; P  = 0.004), mitral valve replacement (OR = 3.9; P  = 0.05), emergent procedure (OR = 3.4; P  = 0.014) and conversion to sternotomy (OR = 3.7; P  = 0.001). Multivariable regression analysis revealed that retrograde perfusion was an independent risk factor for stroke (OR = 3.3; P  = 0.004). Other risk factors were conversion to sternotomy (OR = 12; P  = 0.001), active endocarditis (OR = 5.8; P  = 0.07) and hypercholesterolaemia (OR = 2.4; P  = 0.048). Interaction modelling revealed that the only significant risk factor for a neurological event was the use of retrograde perfusion in patients older than 70 years with an atherosclerotic burden (OR = 6.4; P  = 0.033).ConclusionsMinimally invasive mitral valve procedures can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications in older patients with atherosclerotic burden. Central aortic cannulation permits avoidance of complications associated with retrograde perfusion and extends the suitability of minimally invasive mitral procedures to those patients who have an absolute contraindication for femoral artery cannulation.© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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