Risk Assessment in Cannulation for Minimally Invasive Heart Valve Surgery: The Modified HOSTILE Score

<b>Objectives:</b> The HOSTILE score was developed to assess femoral access challenges in transcatheter valve therapy. Similar vascular issues arise in femoral cannulation for minimally invasive valve surgery, making CT-based planning essential. We adapted the score for surgical use (MOD-HOSTILE) and evaluated its association with neurological and adverse outcomes. <b>Methods:</b> In this single-center retrospective study, the MOD-HOSTILE score (0-11 points) was calculated for 364 patients undergoing minimally invasive heart valve surgery from 2019 to 2023. Patients were stratified into low (0-2), mild (>2-5), and high (>5-11) score categories. Outcomes included 30-day stroke, other neurological events, and perioperative complications. <b>Results:</b> High MOD-HOSTILE patients were significantly older (70 [64.7-73.0] vs. 61 [60.0-63.0] years; <i>p</i> < 0.01) and had higher surgical risk (EuroSCORE II 1.79 [1.26-2.16] vs. 0.83 [0.75-0.94]; <i>p</i> < 0.01). Neurological complications were more frequent in the high MOD-HOSTILE group, including stroke (8.7% vs. 0.9%; <i>p</i> = 0.02) and hemiplegia (13.0% vs. 0.9%; <i>p</i> < 0.01). Axillary cannulated patients had higher MOD-HOSTILE scores than femoral cannulated patients. Stroke risk was highest in patients with high MOD-HOSTILE score undergoing axillary cannulation (high vs. low MOD-HOSTILE, 18.2% vs. 0%; <i>p</i> = 0.04). Thirty-day mortality was comparable between groups (<i>p</i> = 0.09). MOD-HOSTILE predicted stroke with an AUC of 0.78 (95% CI 0.73-0.82) and OR 1.4 per point (95% CI 1.1-2.0). <b>Conclusions:</b> The MOD-HOSTILE score identifies vascular and neurological risk in minimally invasive valve surgery, with scores ≥5 indicating elevated risk of stroke and delirium. Patients with high scores may benefit from alternative surgical strategies.