Clinical Safety and Effectiveness of Endoaortic as Compared to Transthoracic Clamp for Small Thoracotomy Mitral Valve Surgery: Meta-Analysis of Observational Studies
2016; Elsevier BV; Volume: 103; Issue: 2 Linguagem: Inglês
10.1016/j.athoracsur.2016.08.072
ISSN1552-6259
AutoresMariusz Kowalewski, Pietro Giorgio Malvindi, Piotr Suwalski, Giuseppe Maria Raffa, Wojciech Pawliszak, Damian Perlinski, Magdalena Ewa Kowalkowska, Janusz Kowalewski, Thierry Carrel, Lech Anisimowicz,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoControversies remain on the increased rate of neurological events after small thoracotomy mitral valve surgery attributed to endoaortic balloon occlusion (EABO). Systematic literature search of databases identified 17 studies enrolling 6,643 patients comparing safety and effectiveness of EABO versus transthoracic clamp. In a meta-analysis, there was no difference in occurrence of cerebrovascular events, all-cause mortality, and kidney injury. EABO was associated with a significantly higher risk of iatrogenic aortic dissection (0.93% versus 0.13%; risk ratio, 4.67; 95% confidence interval, 1.62 to 13.49; p = 0.004) and a trend toward longer operative times. The data is limited to observational studies. Controversies remain on the increased rate of neurological events after small thoracotomy mitral valve surgery attributed to endoaortic balloon occlusion (EABO). Systematic literature search of databases identified 17 studies enrolling 6,643 patients comparing safety and effectiveness of EABO versus transthoracic clamp. In a meta-analysis, there was no difference in occurrence of cerebrovascular events, all-cause mortality, and kidney injury. EABO was associated with a significantly higher risk of iatrogenic aortic dissection (0.93% versus 0.13%; risk ratio, 4.67; 95% confidence interval, 1.62 to 13.49; p = 0.004) and a trend toward longer operative times. The data is limited to observational studies. The Supplemental Tables and Figures can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2016.08.072] at http://www.annalsthoracicsurgery.org.Over the last 20 years, minimally invasive mitral valve surgery (MIMVS) has established itself as an alternative to conventional sternotomy approach and has increasingly been used for patients with mitral pathology. Rather than single approach, MIMVS refers to a collection of techniques and operation-specific technologies such as modified perfusion and visualization techniques that are directed toward minimizing surgical access and trauma. Several studies reported promising outcomes with MIMVS as compared to conventional surgery with less pain, shorter hospital stays, faster return to normal activities, superior cosmesis, and potential cost savings [1Modi P. Hassan A. Chitwood Jr., W.R. Minimally invasive mitral valve surgery: a systematic review and meta-analysis.Eur J Cardiothorac Surg. 2008; 34: 943-952Crossref PubMed Scopus (342) Google Scholar, 2Walther T. Falk V. Metz S. et al.Pain and quality of life after minimally invasive versus conventional cardiac surgery.Ann Thorac Surg. 1999; 67: 1643-1647Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar, 3Cohn L.H. Adams D.H. Couper G.S. et al.Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.Ann Surg. 1997; 226 (discussion 427–8): 421-426Crossref PubMed Scopus (433) Google Scholar, 4Lapenna E. Torracca L. De Bonis M. La Canna G. Crescenzi G. Alfieri O. Minimally invasive mitral valve repair in the context of Barlow's disease.Ann Thorac Surg. 2005; 79: 1496-1499Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Two techniques of aortic occlusion have been extensively reviewed in the literature: transthoracic clamp (TTC) and endoaortic balloon occlusion (EABO). The first technique uses specifically designed clamp that is introduced through intercostal spaces and positioned around the ascending aorta; it requires positioning of the needle below it for the delivery of cardioplegia and aortic root venting [5Chitwood Jr., W.R. Elbeery J.R. Moran J.F. Minimally invasive mitral valve repair using transthoracic aortic occlusion.Ann Thorac Surg. 1997; 63: 1477-1479Abstract Full Text PDF PubMed Scopus (181) Google Scholar]; the alternative endoaortic balloon comprises a triple lumen catheter mostly introduced via femoral artery with an inflatable balloon at the tip and a central lumen for delivery of cardioplegia and aortic root venting; remaining lumina serve for balloon inflation-deflation and pressure monitoring. The Supplemental Tables and Figures can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2016.08.072] at http://www.annalsthoracicsurgery.org. Although some of the previous studies comparing these 2 techniques reported slightly longer aortic cross-clamp and cardiopulmonary bypass (CPB) times [6Mazine A. Pellerin M. Lebon J.S. Dionne P.O. Jeanmart H. Bouchard D. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes.Ann Thorac Surg. 2013; 96: 2116-2122Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 7Loforte A. Luzi G. Montalto A. et al.Video-assisted minimally invasive mitral valve surgery: external aortic clamp versus endoclamp techniques.Innovations (Phila). 2010; 5: 413-418Crossref PubMed Google Scholar, 8Krapf C. Wohlrab P. Haussinger S. et al.Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate?.Eur J Cardiothorac Surg. 2013; 44: 898-904Crossref PubMed Scopus (24) Google Scholar] with EABO, they remain inconclusive about possible differences in perioperative outcomes. In particular neurologic complications are of interest. The application of an external cross-clamp to an atherosclerotic ascending aorta increases the risk of embolic events and traumatic injury of the aorta [9Guerrieri Wolf L. Abu-Omar Y. Choudhary B.P. Pigott D. Taggart D.P. Gaseous and solid cerebral microembolization during proximal aortic anastomoses in off-pump coronary surgery: the effect of an aortic side-biting clamp and two clampless devices.J Thorac Cardiovasc Surg. 2007; 133: 485-493Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 10Pawliszak W. Kowalewski M. Raffa G.M. et al.Cerebrovascular events after no-touch off-pump coronary artery bypass grafting, conventional side-clamp off-pump coronary artery bypass, and proximal anastomotic devices: a meta-analysis.J Am Heart Assoc. 2015; 5 (Available at http://dx.doi.org/10.1161/JAHA.115.002802): e002802Google Scholar]; similarly, EABO may cause mobilization and embolism of aortic plaques and, in case of dislocation or malposition, the occlusion of innominate artery [11Maselli D. Pizio R. Musumeci F. Multifrequency transcranial Doppler for intraoperative automatic detection and characterisation of cerebral microemboli during port-access mitral valve surgery.Interact Cardiovasc Thorac Surg. 2006; 5: 32-35Crossref PubMed Scopus (6) Google Scholar]. In absence of randomized controlled trials we aimed to perform an updated and comprehensive meta-analysis of observational data on the comparison of endoaortic balloon versus TTC for small thoracotomy MVS with particular emphasis on neurologic complications. Established methods were used in compliance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement [12Liberati A. Altman D.G. Tetzlaff J. et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.BMJ. 2009; 339: b2700Crossref PubMed Scopus (11141) Google Scholar]. PubMed, CINAHL, CENTRAL, and Google Scholar databases were screened for published observational studies comparing EABO versus TTC during MIMVS. Additionally, we browsed congress proceedings from major American and European cardiovascular and cardiothoracic surgery sessions for abstracts available online and reporting outcomes of interest. The following keywords were used: transthoracic clamp, extra-aortic clamp, external aortic clamp, MICRO technique, Chitwood clamp, Portaclamp, direct aortic clamping, endoclamp, endoaortic clamp, endo-balloon, endoluminal clamp endo-aortic balloon occlusion, IntraClude, RAP (Remote Access Perfusion) ESTECH, Heartport, Edwards Endoreturn, EndoClamp, random*, trial, study. Only English full-text publications and abstracts were considered for inclusion. Databases were screened until January 31, 2015. The most updated or inclusive data for each study were used for abstraction. References of original articles were cross-checked for additional relevant reports. Citations were screened at title or abstract level and retrieved as full reports provided they fulfilled the inclusion criteria: (1) human studies, (2) randomized or observational design, (3) studies directly comparing EABO versus TTC during small thoracotomy MVS and reporting clinical outcomes, and (4) substudies or subgroup analyses from small thoracotomy MVS cohorts or registries reporting separately clinical outcomes for EABO versus TTC comparison. Reports were excluded if they (1) were a single-arm design; (2) were studies comparing either EABO or TTC versus fibrillating arrest approach, beating heart CPB, or conventional median sternotomy MVS; (3) involved non-MVS; or (4) had clinical outcomes not reported separately for MV subset of patients. Two independent reviewers (M.K. and W.P.) selected the studies for the inclusion and extracted studies and patient characteristics of interest as well as relevant outcomes; divergences were resolved by consensus after discussion with a third reviewer (L.A.). Three authors (M.K., W.P., and M.E.K.) independently assessed the trials' eligibility and risk of bias. Quality of observational studies was appraised with Newcastle–Ottawa Scale (NOS), a tool used for assessing the bias (the selection of the study groups, the comparability of the groups, and the ascertainment of either the exposure or outcome of interest) in case-control and cohort studies included in a systematic review or meta-analyses [13Lo C.K. Mertz D. Loeb M. Newcastle-Ottawa Scale: comparing reviewers' to authors' assessments.BMC Med Res Methodol. 2014; 14: 45Crossref PubMed Scopus (912) Google Scholar]. The NOS assigns up to a maximum of 9 points for the least risk of bias in 3 domains: (1) selection of study groups (4 points), (2) comparability of groups (2 points), and (3) ascertainment of exposure and outcomes (3 points) for case-control and cohort studies, respectively. Points were assigned if the maximum score (***) was achieved in single domain. The primary endpoint was the incidence of cerebrovascular accident (CVA) at less than 30 days after small thoracotomy MVS. Secondary outcomes were all-cause mortality, acute kidney injury, iatrogenic aortic dissection (IAD), and leg ischemia. Analyses of aortic cross-clamp and CPB duration were performed as well. Study definitions for clinical outcomes were applied. Risk ratios (RRs) and 95% confidence intervals (CIs) served as summary statistics. For dichotomous outcomes. event rates were calculated and are reported as crude rates and weighted event rates using random-effects model inverse variance approach [14Shuster J.J. Walker M.A. Low-event-rate meta-analyses of clinical trials: implementing good practices.Stat Med. 2016; 35: 2467-2478Crossref PubMed Scopus (26) Google Scholar]. Heterogeneity was assessed by Cochran Q test [15Seeger P. Gabrielsson A. Applicability of the Cochran Q test and the F test for statistical analysis of dichotomous data for dependent samples.Psychol Bull. 1968; 69: 269-277Crossref PubMed Scopus (40) Google Scholar]. The results of all studies were combined using a random-effects model [16Riley R.D. Higgins J.P. Deeks J.J. Interpretation of random effects meta-analyses.BMJ. 2011; 342: d549Crossref PubMed Scopus (1554) Google Scholar]. For continuous outcomes, mean difference and corresponding 95% CI were calculated. Whenever a single study reported median values and interquartile ranges instead of mean ± SD, the latter were approximated as described by Wan and colleagues [17Wan X. Wang W. Liu J. Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.BMC Med Res Methodol. 2014; 14: 135Crossref PubMed Scopus (3917) Google Scholar]. Publication bias was examined for the primary endpoint by constructing a "funnel plot" in which the SE of the log RR was plotted against the RR. The asymmetry of the plot was estimated both visually and by a linear regression approach [18Sterne J.A. Sutton A.J. Ioannidis J.P. et al.Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials.BMJ. 2011; 343: d4002Crossref PubMed Scopus (3812) Google Scholar]. By means of metaregression we investigated the potential association between risk difference of primary endpoint and (1) publication date, (2) patients' mean age, (3) rate of previous cardiac surgery, (4) left ventricular ejection fraction, and (5) MV repair rate as approximation of severity of valvular disease. The influence analysis was performed by testing whether deleting each study one at a turn would have changed significantly the pooled results of the meta-analysis for the primary endpoint. As further sensitivity analyses we repeated the calculations for primary endpoint after deleting studies in which ante(ro)grade aortic perfusion instead of retrograde aortic perfusion through femoral artery was employed and studies available as abstract or poster only. We addressed the potential publication bias by performing a regression analysis plotting the risk difference of single dichotomous outcomes against the NOS score. Review Manager V.5.1 (The Nordic Cochrane Centre, Copenhagen, Denmark) and Comprehensive Meta-Analysis, v. 2 (Biostat, Englewood Cliffs, NJ) were used for statistical computations. All p values were significant less than or equal to 0.05 and reported as 2-sided. Process of study selection is shown in the analysis flow diagram (Fig 1). From initial 3,901 records 3,869 were excluded based on the title or abstract content. Thirty-two studies were deemed eligible and retrieved as full text. Fifteen studies did not reach the explicit inclusion criteria and were not included in the quantitative analysis: among them 3 studies were excluded because compared small thoracotomy MVS and EABO versus sternotomy and TTC [19Ryan W.H. Brinkman W.T. Dewey T.M. Mack M.J. Prince S.L. Herbert M.A. Mitral valve surgery: comparison of outcomes in matched sternotomy and port access groups.J Heart Valve Dis. 2010; 19 (discussion 59): 51-58PubMed Google Scholar, 20Srivastava V, Nasir A, Rose D, et al. Using the endoclamp for cardiac surgery improves patient outcomes: a propensity matched comparison with sternotomy patients. Paper presented at: 14 ISMICS; May 28–31, 2014; Boston, MA. Available at http://meetings.ismics.org/abstracts/2014/P93.cgi. Accessed January 31, 2016.Google Scholar, 21Ryan W.H. Dewey T.M. Mack M.J. Herbert M.A. Prince S.L. Mitral valve surgery using the classical 'heartport' technique.J Heart Valve Dis. 2005; 14 (discussion 714): 709-714PubMed Google Scholar]; another 2 studies compared EABO versus TTC for diverse heart surgery procedures and did not report clinical outcomes separately for small thoracotomy MVS [8Krapf C. Wohlrab P. Haussinger S. et al.Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate?.Eur J Cardiothorac Surg. 2013; 44: 898-904Crossref PubMed Scopus (24) Google Scholar, 22Zingone B. Gatti G. Rauber E. Pappalardo A. Benussi B. Dreas L. Surgical management of the atherosclerotic ascending aorta: is endoaortic balloon occlusion safe?.Ann Thorac Surg. 2006; 82: 1709-1714Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Eventually, 17 studies [6Mazine A. Pellerin M. Lebon J.S. Dionne P.O. Jeanmart H. Bouchard D. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes.Ann Thorac Surg. 2013; 96: 2116-2122Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 7Loforte A. Luzi G. Montalto A. et al.Video-assisted minimally invasive mitral valve surgery: external aortic clamp versus endoclamp techniques.Innovations (Phila). 2010; 5: 413-418Crossref PubMed Google Scholar, 23Atluri P. Goldstone A.B. Fox J. Szeto W.Y. Hargrove W.C. Port access cardiac operations can be safely performed with either endoaortic balloon or Chitwood clamp.Ann Thorac Surg. 2014; 98 (discussion 1583–4): 1579-1583Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 24Aybek T. Dogan S. Wimmer-Greinecker G. Westphal K. Mortiz A. The micro-mitral operation comparing the Port-Access technique and the transthoracic clamp technique.J Card Surg. 2000; 15: 76-81Crossref PubMed Scopus (35) Google Scholar, 25Bentala M. Heuts S. Vos R. et al.Comparing the endo-aortic balloon and the external aortic clamp in minimally invasive mitral valve surgery.Interact Cardiovasc Thorac Surg. 2015; 21: 359-365Crossref PubMed Scopus (16) Google Scholar, 26Glower D.D. Desai B. Transaortic endoclamp for mitral valve operation through right minithoracotomy in 369 patients.Innovations (Phila). 2010; 5: 394-399Crossref PubMed Scopus (12) Google Scholar, 27Ius F. Mazzaro E. Tursi V. et al.Clinical results of minimally invasive mitral valve surgery: endoaortic clamp versus external aortic clamp techniques.Innovations (Phila). 2009; 4: 311-318Crossref PubMed Scopus (13) Google Scholar, 28Kempfert J, Meyer A, Cetinkaya A, et al. Propensity matched comparison of endoclamping versus direct aortic clamping for minimally invasive mitral valve surgery. Paper presented at: 15 ISMICS; June 3–6, 2015, Berlin, Germany. Available at http://meetings.ismics.org/abstracts/2015/P99.cgi. Accessed January 31, 2016.Google Scholar, 29Liebold A, Skrabal C, Emini R, Liewald C, Albrecht G, Gorki H. Improved outcome of minimally invasive mitral surgery with IntraClude aortic balloon occlusion compared to transthoracic clamping. Paper presented at: 14 ISMICS; May 28–31, 2014, Boston, MA. Available at http://epostersonline.s3.amazonaws.com/ismics2014/ismics2014.09c0088.NORMAL.pdf. Accessed January 31, 2016.Google Scholar, 30Maselli D. Pizio R. Borelli G. Musumeci F. Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli.Interact Cardiovasc Thorac Surg. 2006; 5: 183-186Crossref PubMed Scopus (28) Google Scholar, 31Mishra Y.K. Malhotra R. Mehta Y. Sharma K.K. Kasliwal R.R. Trehan N. Minimally invasive mitral valve surgery through right anterolateral minithoracotomy.Ann Thorac Surg. 1999; 68: 1520-1524Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 32Modi P. Rodriguez E. Hargrove 3rd, W.C. Hassan A. Szeto W.Y. Chitwood Jr., W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 33Murzi M. Cerillo A.G. Miceli A. et al.Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.Eur J Cardiothorac Surg. 2013; 43: e167-e172Crossref PubMed Scopus (79) Google Scholar, 34Onnasch J.F. Schneider F. Falk V. Mierzwa M. Bucerius J. Mohr F.W. Five years of less invasive mitral valve surgery: from experimental to routine approach.Heart Surg Forum. 2002; 5: 132-135PubMed Google Scholar, 35Reichenspurner H. Detter C. Deuse T. Boehm D.H. Treede H. Reichart B. Video and robotic-assisted minimally invasive mitral valve surgery: a comparison of the Port-Access and transthoracic clamp techniques.Ann Thorac Surg. 2005; 79 (discussion 490–1): 485-490Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 36Ricci D, Barbero C, ElQuarra S, et al. Minimally invasive video-assisted mitral valve surgery with a patient's tailored approach: results of 624 consecutive procedures. Paper presented at: AATS Mitral Conclave; April 23–24, 2015; New York, NY. Available at http://aats.org/mitral/abstracts/2015/P53.cgi. Accessed January 31, 2016.Google Scholar, 37Rinaldi M. Krakor R. Bentala M. et al.Endoaortic balloon clamping and transthoracic aortic clamping are both safe and effective in minimally invasive mitral valve surgery.Interact Cardiovasc Thorac Surg. 2014; 19 Suppl 1 (Available at http://dx.doi.org/10.1093/icvts/ivu276.232): S69Crossref Google Scholar] enrolling 6,643 patients were included in the meta-analysis. Four studies were available as conference abstract or poster only [28Kempfert J, Meyer A, Cetinkaya A, et al. Propensity matched comparison of endoclamping versus direct aortic clamping for minimally invasive mitral valve surgery. Paper presented at: 15 ISMICS; June 3–6, 2015, Berlin, Germany. Available at http://meetings.ismics.org/abstracts/2015/P99.cgi. Accessed January 31, 2016.Google Scholar, 29Liebold A, Skrabal C, Emini R, Liewald C, Albrecht G, Gorki H. Improved outcome of minimally invasive mitral surgery with IntraClude aortic balloon occlusion compared to transthoracic clamping. Paper presented at: 14 ISMICS; May 28–31, 2014, Boston, MA. Available at http://epostersonline.s3.amazonaws.com/ismics2014/ismics2014.09c0088.NORMAL.pdf. Accessed January 31, 2016.Google Scholar, 36Ricci D, Barbero C, ElQuarra S, et al. Minimally invasive video-assisted mitral valve surgery with a patient's tailored approach: results of 624 consecutive procedures. Paper presented at: AATS Mitral Conclave; April 23–24, 2015; New York, NY. Available at http://aats.org/mitral/abstracts/2015/P53.cgi. Accessed January 31, 2016.Google Scholar, 37Rinaldi M. Krakor R. Bentala M. et al.Endoaortic balloon clamping and transthoracic aortic clamping are both safe and effective in minimally invasive mitral valve surgery.Interact Cardiovasc Thorac Surg. 2014; 19 Suppl 1 (Available at http://dx.doi.org/10.1093/icvts/ivu276.232): S69Crossref Google Scholar]. All studies were observational in design: in 5 studies data were collected prospectively [6Mazine A. Pellerin M. Lebon J.S. Dionne P.O. Jeanmart H. Bouchard D. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes.Ann Thorac Surg. 2013; 96: 2116-2122Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 7Loforte A. Luzi G. Montalto A. et al.Video-assisted minimally invasive mitral valve surgery: external aortic clamp versus endoclamp techniques.Innovations (Phila). 2010; 5: 413-418Crossref PubMed Google Scholar, 24Aybek T. Dogan S. Wimmer-Greinecker G. Westphal K. Mortiz A. The micro-mitral operation comparing the Port-Access technique and the transthoracic clamp technique.J Card Surg. 2000; 15: 76-81Crossref PubMed Scopus (35) Google Scholar, 30Maselli D. Pizio R. Borelli G. Musumeci F. Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli.Interact Cardiovasc Thorac Surg. 2006; 5: 183-186Crossref PubMed Scopus (28) Google Scholar, 32Modi P. Rodriguez E. Hargrove 3rd, W.C. Hassan A. Szeto W.Y. Chitwood Jr., W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar]. Propensity score matching was performed in 2 studies [28Kempfert J, Meyer A, Cetinkaya A, et al. Propensity matched comparison of endoclamping versus direct aortic clamping for minimally invasive mitral valve surgery. Paper presented at: 15 ISMICS; June 3–6, 2015, Berlin, Germany. Available at http://meetings.ismics.org/abstracts/2015/P99.cgi. Accessed January 31, 2016.Google Scholar, 33Murzi M. Cerillo A.G. Miceli A. et al.Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.Eur J Cardiothorac Surg. 2013; 43: e167-e172Crossref PubMed Scopus (79) Google Scholar]. Study design, modes of aortic occlusion, aortic perfusion, and patients' baseline characteristics (age, gender, atrial fibrillation, history of CVA, and left ventricular ejection fraction) are listed in Table 1. Retrograde aortic perfusion through femoral artery was employed in 13 studies. Remaining procedural characteristics, MV pathology, and CPB and aortic cross-clamp duration are available in Supplemental Table 1. Statistically, redo surgeries were more frequent in the EABO subset. Characteristics of the mitral pathology were poorly described: universally there was higher proportion of mitral regurgitation as compared to stenosis. MV repair was preferred approach with repair rates ranging from 25% to 100% without marked differences between EABO and TTC. Quality appraisal and potential sources of bias in included studies are reported in Supplemental Table 2.Table 1Included Studies and Patients Baseline CharacteristicsStudyStudy TypeComparatornAge (years)Male (%)AF (%)Previous stroke (%)LVEF (%)Atluri et al 2014 23Atluri P. Goldstone A.B. Fox J. Szeto W.Y. Hargrove W.C. Port access cardiac operations can be safely performed with either endoaortic balloon or Chitwood clamp.Ann Thorac Surg. 2014; 98 (discussion 1583–4): 1579-1583Abstract Full Text Full Text PDF PubMed Scopus (22) Google ScholarretrospectiveEndoClamp Aortic Catheter (Edwards Lifesciences Corporation, Irvine, CA)87559.4 ± 12.657.5aCharacteristics significantly differed between patients in the 2 groups.5.6NA55.3 ± 10.6Chitwood clamp (Scanlan International, Inc, St Paul, MN)18958.9 ± 15.947.6aCharacteristics significantly differed between patients in the 2 groups.6.3NA55.8 ± 11.6Aybek et al 2000 24Aybek T. Dogan S. Wimmer-Greinecker G. Westphal K. Mortiz A. The micro-mitral operation comparing the Port-Access technique and the transthoracic clamp technique.J Card Surg. 2000; 15: 76-81Crossref PubMed Scopus (35) Google ScholarprospectiveHeartport Endoaortic Clamp (Heartport, Redwood City, CA)2358.3 ± 16.447.8NA065.6 ± 13.4Chitwood clamp (Scanlan International, Inc, St Paul, MN)3556.3 ± 12.954.3NA2.960.6 ± 10.7Bentala et al 2015 25Bentala M. Heuts S. Vos R. et al.Comparing the endo-aortic balloon and the external aortic clamp in minimally invasive mitral valve surgery.Interact Cardiovasc Thorac Surg. 2015; 21: 359-365Crossref PubMed Scopus (16) Google ScholarretrospectiveEndoClamp Aortic Catheter, IntraClude Intra-Aortic Occlusion Device (Edwards Lifesciences Corporation, Irvine, CA)16466 (60–74)bMedian (interquartile range).56.137.81.9>5045.5aCharacteristics significantly differed between patients in the 2 groups.Chitwood clamp (Scanlan International, Inc, St Paul, MN)5762 (57–73)bMedian (interquartile range).56.143.97.0>5068.7aCharacteristics significantly differed between patients in the 2 groups.Glower et al 2010 26Glower D.D. Desai B. Transaortic endoclamp for mitral valve operation through right minithoracotomy in 369 patients.Innovations (Phila). 2010; 5: 394-399Crossref PubMed Scopus (12) Google ScholarretrospectiveEndoClamp Aortic Catheter (Edwards Lifesciences Corporation, Irvine, CA)43659 ± 1347.534.6NA51 ± 12aCharacteristics significantly differed between patients in the 2 groups.Cosgrove Flex Clamp (Cardinal Health V, Edwards Lifesciences Corporation, Irvine, CA)23558 ± 1440.932.353 ± 10aCharacteristics significantly differed between patients in the 2 groups.Ius et al 2009 27Ius F. Mazzaro E. Tursi V. et al.Clinical results of minimally invasive mitral valve surgery: endoaortic clamp versus external aortic clamp techniques.Innovations (Phila). 2009; 4: 311-318Crossref PubMed Scopus (13) Google ScholarretrospectiveEndoClamp Aortic Catheter (Edwards Lifesciences Corporation, Irvine, CA)cPropensity score matching performed.3263 ± 959.428.1NA64 ± 8Cygnet Flexible Clamp (Novare Surgical Systems Inc., Cupertino, CA)cPropensity score matching performed.9562 ± 1149.528.465 ± 8Kempfert et al 2015 28Kempfert J, Meyer A, Cetinkaya A, et al. Propensity matched comparison of endoclamping versus direct aortic clamping for minimally invasive mitral valve surgery. Paper presented at: 15 ISMICS; June 3–6, 2015, Berlin, Germany. Available at http://meetings.ismics.org/abstracts/2015/P99.cgi. Accessed January 31, 2016.Google ScholarretrospectivecPropensity score matching performed.IntraClude Intra-Aortic Occlusion Device (Edwards Lifesciences Corporation, Irvine, CA)37NANANANANAChitwood clamp (Scanlan International, Inc, St Paul, MN)37Liebold et al 2014 29Liebold A, Skrabal C, Emini R, Liewald C, Albrecht G, Gorki H. Improved outcome of minimally invasive mitral surgery with IntraClude aortic balloon occlusion compared to transthoracic clamping. Paper presented at: 14 ISMICS; May 28–31, 2014, Boston, MA. Available at http://epostersonline.s3.amazonaws.com/ismics2014/ismics2014.09c0088.NORMAL.pdf. Accessed January 31, 2016.Google ScholarretrospectiveIntraClude Intra-Aortic Occlusion Device (Edwards Lifesciences Corporation, Irvine, CA)5061.8 ± 14NANANANAChitwood clamp (Scanlan International, Inc, St Paul, MN)50Loforte et al 2010 7Loforte A. Luzi G. Montalto A. et al.Video-assisted minimally invasive mitral valve surgery: external aortic clamp versus endoclamp techniques.Innovations (Phila). 2010; 5: 413-418Crossref PubMed Google ScholarprospectiveEndoClamp Aortic Catheter (Edwards Lifesciences Corporation, Irvine, CA)cPropensity score matching performed.4558.1 ± 11.422.333.3NA58 ± 8.6Cygnet Flexible Clamp (Novare Surgical Systems Inc., Cupertino, CA)cPropensity score matching performed.9358.8 ± 7.826.932.260 ± 9.5Maselli et al 2006 30Maselli D. Pizio R. Borelli G. Musumeci F. Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli.Interact Cardiovasc Thorac Surg. 2006; 5: 183-186Crossref PubMed Scopus (28) Google ScholarprospectiveCardioVations EndoClamp Aortic Catheter (Edwards Lifesciences Corporation, Irvine, CA)2056.5 ± 6.430NANANAChitwood clamp (Scanlan International, Inc, St Paul, MN)1654.7 ± 5.425Mazine et al 2013 6Mazine A. Pellerin M. Lebon J.S. Dionne P.O. Jeanmart H. Bouchard D. Minimally invasive mitral valve surgery: influence of
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