Pushing The Boundaries Of Endoscopic Cardiac Surgery For Complex Procedures: Double Valve Replacement And Extensive Septal Myectomy
Bleri Çelmeta, MD, Antonio Miceli, MD, Matteo Ferrarini, MD, Mattia Glauber, MD.
Istituto Clinico Sant'Ambrogio, Milan, Italy.
BACKGROUND: Minimally invasive endoscopic cardiac surgery offers several benefits in terms of reduced postoperative pain, bleeding, transfusions and ventilation duration. In this case report video, we demonstrate that this approach and all its benefits can be applied even to complex and multiple cardiac procedures.
METHODS: We present a 71-year-old patient with a history of hypertrophic cardiomyopathy (HCM), atrial fibrillation and previous transient ischemic attack. 5 years after the diagnosis and after an episode of loss of consciousness, multiple diagnostic instruments demonstrated the presence of a severely obstructive HCM (interventricular septum 31 mm, LVOT mean gradient 50 mmHg), moderate mitral regurgitation for SAM, moderate aortic stenosis and regurgitation and severe left atrial dilatation.
RESULTS: We performed a mitro-aortic valve replacement, trans-mitral and trans-aortic septal myectomy and left atrial appendage closure in an endoscopic fashion. A 4 cm right antero-lateral mini-thoracotomy on 4th intercostal space and a 2 cm surgical incision on the left groin were performed for the thoracic and femoral accesses respectively. After peripheric CPB instauration and aortic cross-clamping by means of a removable branches clamp, the left atrium was opened in a standard fashion. The anterior mitral leaflet was incised circumferentially at its insertion on the anulus to allow an optimal trans-mitral myectomy. Afterwards, mitral valve removal was completed and a bioprosthesis was implanted. After left atrial closure, the left atrial appendage was closed by means of a 40 mm clip. Subsequently, the aorta was opened, the aortic valve was excised and a trans-aortic septal myectomy was performed to complete the LVOT unblocking. Finally, a sutureless aortic bioprosthesis was implanted. Postoperative trans-esophageal and trans-thoracic surgery demonstrated a residual LVOT gradient of 14 mmHg and a correct performance of both biological prostheses. The patient needed a permanent pacemaker implantation due to postoperative complete atrioventricular bloc. No blood transfusions were necessary. The patient left our hospital 7 days after the operation to pursue cardiopulmonary rehabilitation elsewhere.
CONCLUSIONS: Endoscopic heart surgery can be offered even to patients requiring complex and multiple procedures. By implementing a minimally invasive approach, we may therefore reduce postoperative pain, need for transfusions and hospital stay.
Back to 2022 Display Videos