Totally Endoscopic Aortic Valve Replacement
Silke Van Genechten1, Alaaddin Yilmaz1, Pascal Starinieri1, Miha Antonič2.
1Jessa hospital, Hasselt, Belgium, 2University medical center Maribor, Maribor, Slovenia.
BACKGROUND Cardiac surgery is looking for new techniques, which are less traumatic and with better functional and cosmetic results. In this report, we present our surgical technique, its feasibility and early results of the first series of totally endoscopic stented aortic valve replacement. The deleterious effects of the cardiopulmonary bypass circuit can be additionally minimized with the use of a minimally invasive extracorporeal circulation (MiECC).
METHODS From October 2017 to December 2017, 10 patients (4 males, mean age: 74.5 ± 9.0 years) underwent a totally endoscopic aortic valve replacement. The inclusion of the patients was based on the surgeon’s discretion. All patients underwent the surgical procedure due to severe aortic valve stenosis. The aorta was accessed through a 20 mm working port in the 2nd right intercostal space and additional three 5 mm trocars. Standard zero-degree optics was used. The right femoral artery and vein were exposed through a 2-cm groin incision and the cardiopulmonary bypass was initiated after the cannulas were positioned under the transoesophageal echocardiographic guidance. Aorta was cross-clamped using a Chitwood clamp and antegrade cold mixed blood cardioplegia (3:1 ratio) was used for myocardial protection. The aortotomy was performed, the stenotic aortic valve excised and a stented biological aortic valve vas implanted in supra-annular position using interrupted pledgeted 2-0 braided polyester sutures. The sutures were tied down using an automated knotting device.
RESULTS The procedure was successful in all patients, requiring no conversion to open surgery. Mean cross-clamping and cardiopulmonary bypass times were 77.7 ± 10.3 and 125.3 ± 22.8 minutes, respectively. The mean length of stay at the intensive care unit and the hospital were 104.83 ± 44.5 hours and 10.5 ± 3.2 days, respectively. Postoperative blood loss was 120.1 ± 85.4 mL. There were no re-explorations for bleeding. No paravalvular leakage was detected at discharge and no early major operative complications were registered.
This approach appears to be safe and feasible with reasonable clamping times. Although experience is limited and follow-up is very short, with further experience this less invasive surgical technique may become a viable option for aortic valve replacement.
Figure 1 (A) Trocar setting during the procedure; (B) Stented aortic valve; (C) Intraoperative endoscopic view; (D) Cosmetic aspect one week post-operatively
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