# Assistance from a mixing zone model to perform aortic femoral perfusion strategy with severe atherosclerotic and artheromic aortic disease for endoscopic minimally invasive redo mitral valve repair

## TL;DR

A new perfusion strategy is used in minimally invasive heart surgery to reduce the risk of brain complications in patients with severe aortic disease.

## Contribution

A mixing zone model is introduced to optimize antegrade and retrograde perfusion in high-risk cardiac surgery.

## Key findings

- Combined antegrade and retrograde perfusion can be safely used in redo mitral valve surgery with a diseased aorta.
- Reducing the ascending aorta cannulation size relative to the femoral artery improves perfusion outcomes.
- The patient recovered without cerebral complications using the described strategy.

## Abstract

Minimally invasive cardiac surgery (MICS) for redo mitral valve surgery in the presence of severe atheroma and atherosclerotic diseased atherosclerotic and artheromic aorta presents significant challenges and increases the risk of postoperative cerebral infarction. At our institution, to mitigate the risk of postoperative cerebral complications, we employ a strategy combining antegrade and retrograde perfusion during MICS for patients with atherosclerotic and artheromic aorta. However, the mixing zone during cardiopulmonary bypass (CPB) with combined antegrade and retrograde perfusion has not been thoroughly evaluated. In this case, we performed a completely endoscopic MICS redo mitral valve plasty (MVP). CPB was established using cannulation of both the ascending aorta (Asc Ao) and the femoral artery (FA). The patient received planned systemic hyperkalemia without an aortic cross clamp. In addition, due to aortic insufficiency, circulatory arrest was also needed. The patient experienced an uneventful post-operative recovery without any cerebral complication. Furthermore, we evaluated the mixing zone during the combined antegrade and retrograde perfusion using an arteriovenous circulation model. Our findings suggest that when performing perfusion via the Asc Ao and FA, it is advisable to select Asc Ao cannulation size reduced by one size against FA cannulation size to optimize the procedure.