Such an approach has been shown to be effective by Murphy selleck kinase inhibitor et al. [76], who demonstrated a 1.6% stroke rate using retrograde perfusion in similarly screened patients undergoing robotic cardiac procedures. Minimally invasive valve surgery with antegrade perfusion has a low risk of neurological complications and has excellent outcomes. Retrograde perfusion in older patients with significant vascular comorbidities is associated with an increased risk of stroke. The vast majority of patients currently undergo heart valve procedures through a right anterior minithoracotomy with antegrade perfusion via direct ascending aorta cannulation obviating the concerns associated with retrograde perfusion. For those procedures in which the direct access to the ascending aorta is extremely limited, in a recent editorials Yaffee et al.
[75] recommend preoperative aortic screening to identify aortic pathology and to avoid retrograde perfusion in patients where high atheroembolic risk exists. 6. Bleeding, Transfusion, and Reexploration A reduction in postoperative hemorrhage and transfusion requirements has been suggested as a potential advantage of minimally invasive valve surgery. This benefit is important given the significant morbidity and mortality associated with transfusions and reexploration for bleeding [77]. Smaller incisions should theoretically reduce postoperative bleeding and transfusion requirements, notably with the significant morbidity/mortality associated with transfusions and bleeding reexploration. Some studies report no difference in transfusion requirements [45].
Four comparative studies reported blood loss volume with three utilizing a minithoracotomy [28, 31, 66] and one selecting a parasternal approach [42]. Mohr et al. demonstrated no difference in blood loss or blood product transfusions in 31 videoscopic mitral procedures compared with a conventional sternotomy, despite fewer reexplorations for bleeding [28]. The robotically directed technique showed a significant decrease in blood loss as well as ventilator time and hospitalization compared with the sternotomy-based technique [30]. Felger et al. reported that there was no significant difference either in percentage of patients receiving transfusions or in the amount of packed red blood cells, fresh frozen plasma, or platelets transfused; however, postoperative chest tube drainage was significantly less in minimally invasive patients compared Cilengitide with sternotomy patients (P = 0.006). Because extreme values skewed the raw data for ventilator hours, a rank order analysis of variance was performed to provide homogeneity of the data.