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International Society For Minimally Invasive Cardiothoracic Surgery

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Totally Endoscopic Aortic Valve Replacement With Conventional Aortic Prostheses
Antonios Pitsis1, Nikolaos Nikoloudakis1, Nikolaos Tsotsolis1, Harisios Boudoulas2, Konstantinos Dean Boudoulas2
1St. Luke's Hospital, Thessaloniki, Greece, 2The Ohio State University, Columbus, OH, USA

BACKGROUND. Endoscopic mitral and tricuspid procedures have been practiced for the last two decades routinely in many centers. The aortic valve has not been met with the same popularity mainly due to its confined space in the aorta and to its close proximity to the sternum. When totally endoscopic aortic valve replacement (TEAVR) is performed in expert centers, usually it is done with the use of sutureless bioprostheses. We hereby present our experience of TEAVR with conventional mechanical and biological prostheses.METHODS. From January to December 2019, 38 consecutive patients (10,5% REDOs) with significant AS and/or AR were operated with TEAVR using conventional prostheses (79% biological, 21% mechanical). The operations were performed through a 3 cm working incision and a 10mm port for the 3D 30° Karl-Storz endoscope (Fig. 1a). On full CPB, the aorta was cross-clamped with the Chitwood clamp. The heart was arrested with Custodiol cardioplegia. A transverse aortotomy was performed, the native valve was excised and the prostheses were inserted and secured using the COR-KNOT®(Fig. 1b,1c,1d). A self-expandable net (Fehling) was used to expose the root. RESULTS. The average age of the patients studied was 66,6 years (36-81). The mean EuroSCORE2 was 2,89 (0,9-12,01). The mean size of the prostheses inserted was 23,54 mm (21-27) and the mean gradient was 12,9mmHg (SEM:1,39). Mean cross-clamp and CPB times were 73,84min (SEM:6,55) and 116,94 (SEM:10,76). There were no case of paravalvular leak or pacemaker insertion and no in-hospital mortalities; one case of CVA was observed. CONCLUSIONS. TEAVR can be performed safely with conventional prostheses. Although cross-clamp and CBP times are prolonged, there are several advantages of this technique. As compared to traditional SAVR, TEAVR is much less invasive without the need to fracture the sternum or spread the ribs. Over TAVI, TEAVR has the advantages of fully removing the diseased native valve, ability to use mechanical prostheses, and securing the prosthesis at the exact annular level, thus reducing the risk of paravalvular leaks or need for pacemaker insertion. LEGEND. Fig.1a:working incision and ports, 1b:a heavily calcified bicuspid valve, 1c:TEVAR with a bioprosthesis, 1d:TEVAR with a mechanical prosthesis in a REDO case.


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