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International Society For Minimally Invasive Cardiothoracic Surgery

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Totally Endoscopic Redo Tricuspid Repair Without Any Heart Dissection
Antonios Pitsis1, Nikolaos Tsotsolis1, Nikolaos Nikoloudakis1, Harisios Boudoulas2, Konstantinos Dean Boudoulas2.
1St. Luke's Hospital, Thessaloniki, Greece, 2The Ohio State University, Columbus, OH, USA.

BACKGROUND. Redo isolated tricuspid repair carries a high mortality and morbidity. Our totally endoscopic redo tricuspid repair technique (TErTVRepair) avoids entirely heart dissection. METHODS. From January 2018 to December 2019, 12 consecutive patients with significant tricuspid regurgitation and symptoms of right heart failure, were operated with our TErTVRepair technique. Ten patients had a history of mitral valve surgery and two had previous CABG. The operation was performed through a periareolar 2 to 3 cm working incision (Fig.1a). The 3D 30-degree Karl Storz endoscope was inserted through a 10mm port. On full CPB, with femoral and jugular cannulation, and on the beating heart, the right atrium (RA) was entered — en-block with the pericardium —at a safe distance below the atrioventricular groove, without any intrapericardial dissection or snaring of the superior or inferior vena cava (Fig.1b). Air lock was avoided by carefully adjusting the vacuum assist. Our TErTVRepair includes the closure of the anteroposterior commissure, creating a bicuspid valve (Fig.1c) and an annuloplasty using bands (Fig.1d). The atriotomy (en-block with the pericardium) was closed with a running suture. RESULTS. The average age of the patients treated was 68,16 (61-83) and the mean NYHA class was 3,33 (SEM:0,49). The mean EuroSCORE2 was 6,05 (SEM:0,63). All the patients had grade 4+ TR preoperatively which was reduced to less than 1+) postoperatively (mean:0,54, SEM:0,35). The tricuspid annulus diameter was reduced from 43,41mm (SEM: 1,47) to 25,58mm (SEM: 1,22). The postoperative peak tricuspid gradient was 3,62mmHg (SEM: 0,53). The mean CPB time was 74,83min (SEM: 10,68). There was no mortality. All of the patients were extubated within the 1st postoperative day. CONCLUSIONS. Our TErTVRepair approach is quite minimalistic (no heart dissection at all) while offers an excellent exposure of the tricuspid valve. The closure of the anteroposterior commissure is another key point of this technique and we believe that it helps to avoid TR recurrence. Importantly this technique is fast and safe, transforming a high-risk procedure to a low-risk one. LEGENDS. Fig.1.a: working incision and ports in TErTVRepair, b: endoscopic view of the tricuspid valve, c: closure of the anteroposterior commissure, d: annuloplasty with a band.


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