International Society For Minimally Invasive Cardiothoracic Surgery

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Totally Endoscopic Trans-axillary Aortic Valve Replacement
Masayoshi Tokoro, Toshiaki Ito, Atsuo Maekawa.
Japanese Red Cross Nagoya First Hospital, Nagoya City, Aich Pref., Japan.

Objective: Totally endoscopic aortic valve replacement (AVR) is yet challenging compared with endoscopic mitral valve surgery. We started totally endoscopic AVR, by modifying right trans-axillary AVR (TAX-AVR) technique with the aid of 3-dimensional(3D) endoscope. The purposes of this study were to establish totally endoscopic TAX-AVR (E-TAXAVR) and evaluate its early outcomes. Methods: Surgery: The patient was set in partial left lateral position and a small thoracotomy was made in the 3rd or 4th intercostal space without rib spreader. Left handed port was made in the 2nd or 3rd intercostal space. All procedures were performed using three-dimensional endoscope. Comparison with Conventional TAX-AVR (C-TAXAVR): Between May 2012 and November 2018, Total of 529 patients underwent isolated AVR at our institution. Of them, 48 underwent E-TAXAVR and 156 underwent C-TAXAVR. Early outcomes were compared in these 204 patients. Primary endpoints were major adverse cardiac and cerebrovascular events(MACCE). Secondary endpoints were total surgical time, Cardio-pulmonary bypass (CPB) time, aortic clamp time and post-operative length of ICU and hospital stay. Results: There were no differences in hospital death (0,0), MACCE (0,5) (E-TAXAVR, C-TAXAVR, respectively). Postoperative hospitalization was shorter in E-TAXAVR group (E-TAXAVR vs C-TAXAVR: 7.3±2 days vs 10±3 days, p<0.01). Total surgical time was significantly shorter in E-TAXAVR (E- vs C- : 192±48 min vs 220±72 min, p<0.01) but there were no differences between the two groups in the CPB time and clamp time (E- vs C- : 135±38 min vs 139±46 min p=0.88, 96±33 vs 99±34 min p=0.82, respectively). Continuous variables were expressed as median±interquartile range. Conclusions: TAX-AVR was safe and we could expect quicker recovery. Trans-axillary approach seemed to be suitable for totally endoscopic AVR, especially to obtain appropriate working space necessary for endoscopic surgery. Endoscopic surgery did not prolong operation time compared with direct vison plus endoscopic assist style of original TAX-AVR.

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