Safer Minimally Invasive Cardiac Surgery (MICS): The Impact of Antegrade Perfusion through the Right Axillary Artery on Neurological Complications

Introduction: Connection to the extracorporeal circulation (ECC) for MICS through a right mini-thoracotomy is usually achieved through open direct cannulation of the groin vessels. Retrograde arterial perfusion, however, is possibly associated with postoperative neurological complications. We hypothesized that antegrade perfusion through the right axillary artery would lower the incidence of neurological adverse events in MICS.

Patients and Methods: A retrospective observational study of prospectively collected data of patients undergoing MICS (right mini-thoracotomy) from 10/2002 to 12/2018 divided in two groups according to the cannulated artery (group A: axillary, group F: femoral artery). As neurological complications we considered permanent or transient stroke and / or early postoperative delirium. Propensity score (PS) matching was performed (PS estimated through probit regression) with balance verification of the independent covariates. Statistical analysis was performed with STATA (v.15/Mac).

Results: A total of 260 patients (153 males, 107 females, mean age 62 ± 13 years) with group A (n=56) and group F (n=204) were analyzed. Postoperative mortality was <1% in both groups. Postoperative neurological complications appeared as follows:

The PS was based on sex, age, Euroscore II, ECC duration, postoperative atrial fibrillation. Balance of the covariates was verified (mean bias 1.5%). After matching, the impact of antegrade perfusion was significantly positive: the difference of ATT (average treatment effect on treated) between the groups was 6% (p=0.049).

Conclusions: Antegrade perfusion through the right axillary artery in MICS results in lower incidence of postoperative neurological complications.