International Society For Minimally Invasive Cardiothoracic Surgery

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Totally Endoscopic Aortic Valve Repair Through A Periareolar Incision
Antonios Pitsis, Director, Vasilios Economopoulos, Christos Tourmousoglou, Nikolaos Nikoloudakis, Timotheos Kelpis, Nikolaos Tsotsolis.
St. Luke's Hospital, Thessaloniki, Greece.

OBJECTIVE: Thoracoscopic mitral and tricuspid surgery is accepted as one of the least invasive approaches that cardiac surgery can offer. Periareolar incision has been proposed as a working incision in thoracoscopic surgery because it offers excellent healing and patient satisfaction both in men and women.We have been using the periareolar working incision exclusively in all types of mitral and tricuspid surgery.We hypothesise that the periareolar working incision can also be used for selected aortic valve surgery.
METHODS: A 67 y.o. lady was admitted with history of recurrent chest pain associated with elevated troponin plasma levels and an episode of presyncopal attack. An 8mm mobile pedunculated mass attached to the free edge of the left coronary cusp was found on transesophageal echocardiogram (TEE) and the clinical diagnosis of papillary fibroelastoma was made. Coronary angiogram and computerised tomography of the brain were normal.The symptoms of the patient were thought to be due to embolic events of the fibroelastoma and urgent surgery was advised.
RESULTS: Under general anaesthesia we performed a 3 cm right periareolar incision and we entered through the 3rd intercostal space lateral to the midclavicular line. An extra small Alexis was used. A 30 degrees 3D endoscope was inserted through an incision in the anterior axillary line in the same intercostal space. After going on bypass from the femoral vessels, we mobilised the ascending aorta from the right pulmonary artery and then the aorta was crossclamped with the Chitwood clamp. On cardioplegic arrest, a vent was inserted in the right superior pulmonary vein and the ascending aorta was incised circumferentially, 3 cm above the level of the right ostium.The fibroelastoma was identified in the left cusp neighboring the left coronary ostium. It was resected taking care to spare the cusp. The aortotomy was closed in two layers. TEE confirmed valve competency. Histology confirmed the clinical diagnosis. Patient recovery was excellent.
CONCLUSIONS: Even a small fibroelastoma can cause very serious complications and therefore early resection is advised especially in symptomatic patients.A thoracoscopic approach seems proper having the advantages of the fast recovery and maximum patient satisfaction.

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