These BTB06584? were compared to 14 patients undergoing conventional mitral surgery [36]. They found no significant difference in the cerebral microembolic rate between either technique. The Consensus Statement of the International Society of Minimally Invasive Coronary Surgery (ISMICS) 2010, based on a systematic review and meta-analysis of all available randomized and nonrandomized comparative trials of isolated mini versus conventional mitral valve surgery (two randomized trials and 33 nonrandomized studies for a total of 35 studies) [68], associated some adverse clinical outcomes with mini MVS compared with conv-MVS, including stroke, aortic dissection, and groin wound/vasculature complications. The absolute risk increase of stroke for mini MVS versus conv-MVS was 0.9% overall (2.1% versus 1.

2%, RR 1.79, 95% CI 1.35�C2.38; 13 studies, level B). Subanalysis of two propensity comparison studies also showed significant increase of stroke of 1% with mini MVS compared with conv-MVS (1.9% versus 0.9%, RR 2.02, 95% CI 1.40�C2.94; two studies, level B) [69]. These findings are similar to those recently reported by a recent Society of Thoracic Surgeons-Adult Cardiac Surgical Database (STS-ACSD) publication made on 28,143 patients undergoing isolated mitral valve operations that examined the associations between operative strategy and the increased risk of stroke in the less-invasive group [70]. The markedly higher rate of permanent perioperative stroke in the less-invasive group compared with the conventional sternotomy group in unadjusted, adjusted, and propensity analyses was the most significant finding of this study.

The adjusted OR for permanent stroke was 1.96 for less-invasive compared with conventional sternotomy operations in the multivariable analysis, and the likelihood of stroke was similarly increased in the propensity analysis. Among the 4,322 LIMV operations, there were 41 excess strokes compared with the propensity-matched group having conventional mitral valve operations. Additional analyses demonstrated a threefold higher risk of stroke for less-invasive operations performed without aortic occlusion (beating- or fibrillating-heart), which comprised 12% of the less invasive group. Femoral cannulation was not an independent predictor of stroke [70]. Grossi et al.

[71] using an informal strategy of intraoperative echocardiographic analysis of the aortic arch and the descending aorta in 714 minimally invasive mitral valve procedures had excellent results from this Entinostat approach avoiding the use of femoral perfusion when there was significant atherosclerotic burden [71]. In this cohort, where 30% of patients were >70 years of age, 15% were reoperations, and 12% were multivalve operations, femoral perfusion was used in nearly 80% of patients, with a 2.9% incidence of stroke.

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