International Society For Minimally Invasive Cardiothoracic Surgery

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Does A Single Endoscopic Access For Aortic Valve Replacement Preclude Concomitant Procedures?
tommaso hinna danesi, Giovanni Domenico Cresce, Massimo Sella, Loris Salvador.
Ospedale San Bortolo Vicenza, Vicenza, Italy.

BACKGROUND: To evaluate whether the single endoscopic surgical access for aortic valve replacement is feasible in concomitant mitral,tricuspid or complex procedures. METHODS: We performed a single-institution retrospective analysis of 148 patients (mean age 69.1 11.3 years; 77 males, mean EuroScre II 1.51 1.39) undergoing minimally invasive aortic valve replacement (AVR) over a 5-years period. All surgeries were via a totally endoscopic approach. The surgical access was a single 2.5 cm to 3.5 cm working port in the second right intercostal space without any rib spread or resection; three additional 5 mm mini-ports were made for the introduction of a 30 degree thoracoscope, the ventline and the Chitwood clamp. Cardiopulmonary bypass (CPB) was instituted through a peripheral cannulation.RESULTS: All Patients underwent endoscopic AVR. Over 148 Patients 30 (20.2%) received an additional procedure. Associated procedures were: interventricular septum miectomy in 8 patients, mitral valve repair in 8, mitral valve replacement in 6; ascending aorta plication and replacement in 4 and 2 patient respectively. A triple valve surgery was performed in 2 patients.Mean CPB time was 128 30.4 and 62.344.6 minutes in isolated AVR and combined surgery respectively (p<0.05). Aortic crossclamp time in isolated AVR was 88.8 23.2 and 121.537.2 minutes in combined surgery (p<0.05).One conversion to sternotomy due to intraoperative coronary artery obstruction requiring CABG was needed. Mean ICU was 2.2 2.5 and 5.0 11.7 days in isolated AVR and combined surgery respectively (p=0.01). Hospital stay were and 7.1 4.1 and 9.6 15.7 days in isolated AVR and in combined surgery respectively (p=ns).Thirty-day mortality occurred in 2 patients (1.3%) one in isolated AVR population and one in a concomitant mitral valve repair procedure. Five patient (3.3%) needed a surgical re-exploration for postoperative bleeding (4 in combined surgery group, p=ns). No major neurological events were observed.CONCLUSIONS: This study shows that through a single port endoscopic approach made for AVR a concomitant procedure is feasible and safe in experienced centers. Concomitant surgery can include multiple valve treatment and endoscopically complex operation as the ascending aorta replacement. Additional procedures cause a statistically significant elongation of CPB and cross clamp time and ICU stay, without affecting overall mortality in our series.

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