Endoscopic Cardiac Approach For Aortic Valve Surgery
Giovanni Domenico Cresce, Massimo Sella, Tommaso Hinna Danesi, Loris Salvador.
San Bortolo Hospital, Vicenza, Italy.
Objective: Aim of this study was to describe our minimally invasive endoscopic aortic valve replacement (E-AVR) technique and to evaluate its operative results regardless of the type of prosthetic valve implanted and the preoperative patients characteristics.
Methods: From July 2013 to October 2018, 165 consecutive patients (96 males, mean age 68.7±11.4 years, mean EuroScore II 1.6±1.4) underwent E-AVR. The surgical access was a 3-4 cm. working port in the second right intercostal space with no-rib spreading and without right mammary artery sacrifice; three additional 5 mm. mini-ports for the introduction of a 30-degree thoracoscope, the Chitwood clamp and the vent line were used. Cardiopulmonary by-pass (CPB) was achieved through a femoro-femoral cannulation.
Results: All patients underwent E-AVR. Associated procedures were 34 (20.6%): septal miectomy, mitral valve surgery, combined mitral and tricuspid valve repair and ascending aorta surgery in 8, 14, 3 and 9 cases respectively. Standard stended bioprostheses were implanted in 73 cases, Rapid Deployment and Suturless Bioprostheses in 34 and 58 cases respectively. In the 131 isolated E-AVR, mean aortic cross clamp and CPB times were 87.5±22.6 and 126.6±28.8 minutes respectively and significant reduction was observed when a sutureless valve was implanted: 68.7±14.7 and 105.6±21.8 minutes (Sutureless) vs 93.2±15.1 and 135.5±21.8 minutes (Rapid Deployment) and 100.6±17.2 and 138.9±21.9 minutes (Stented). Mean ventilation, ICU time and hospital stay were 13.9±39.3 hours, 45.6±58.4 hours and 7.6±7.8 days respectively. The overall mortality was 1.2%. Re-exploration for bleeding and new permanent pacemaker implantation occurred in 5 (3%) and 6 (3.6%) cases respectively. No major neurologic events were observed. No paravalvular leakage was detected at discharge. One conversion to sternotomy occurred (0.6%).
Conclusions: Our experience shows that E-AVR is safe and feasible. The use of sutureless valve significantly reduces the aortic cross clamp and the CPB times. Concomitant procedures may be done through the same single working port. With further experience this approach may become the technique of choice for all patients undergoing AVR. 
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