We read the article by Minol et al. [1]. They evaluated the contemporary series of octogenarians undergoing minimally invasive mitral valve surgery using right lateral minithoracotomy to elucidate the preoperative risk profile and the postoperative course. However, there are some contradictory points when compared with literature.
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. There are some studies about perfusion for minimally invasive valve surgery in elderly patients. Grossi and colleagues presented a focused report on a more homogeneous subset of 1282 isolated mitral valve operations performed through a right anterior minithoracotomy over a 12-year period [2]. This homogeneity allowed us greater discriminatory power to analyze the specific patient factors associated with an increased risk of stroke. The only significant risk factor interaction for neurological complication identified was the use of retrograde perfusion in patients with high-risk comorbidities: peripheral vascular disease, cerebrovascular disease, or atherosclerotic aortas. These data suggest that retrograde perfusion remains a viable option for younger patients without vascular comorbidities. In older patients, or those with the risk factors discussed previously, performing a computed tomography angiography of the descending aorta with distal runoff in addition to an intraoperative transoesophageal echocardiographic assessment of the thoracic aorta [2,3] is currently recommended. The incidence of peripheral arterial disease (PAD) is 12.2% in >70 years of age [4]. Regarding the advanced age of patients included in this study, were the participants evaluated for peripheral artery disease? Why did the authors prefer femoral vessel cannulation for all patients? Given the high (>80) average age of patients in this study, we would recommend a preoperative screening for PAD and, if there were no contraindications, it would be safer to use antegrade perfusion in order to prevent postoperative neurological complications.
Conflict of interest: none declared.
References
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