International Society for Minimally Invasive Cardiothoracic Surgery
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Totally Endoscopic Aortic Valve Replacement With Aortic Root Enlargement
TIMOTHEOS G. KELPIS, ANTONIOS A. PITSIS.
European Interbalkan Medical Center, Thessaloniki, Greece.

BACKGROUND: Patients with a small aortic annulus undergoing aortic valve replacement (AVR) are at risk for patient-prosthesis mismatch (PPM). Since PPM following AVR increases all-cause and cardiac-related long-term mortality, an aortic root enlargement (ARE) procedure may be necessary for the implantation of a prosthetic valve of adequate size to prevent PPM. Several minimally invasive AVR techniques have been described. Our objective was to assess the feasibility of a totally endoscopic aortic valve replacement (TEAVR) with ARE. METHODS: From August 2020 to November 2022, 7 patients underwent TEAVR with ARE. TEAVR was performed through a 2cm working incision and two ports (10mm and 5mm). A transverse aortotomy was made and the valve was removed. After sizing the annulus and making the decision to perform an annular enlargement, a vertical incision through the noncoronary sinus just 2mm laterally to the left-non commissure was made. The incision was then continued downwards, dividing the aortic annulus and extended laterally on each side (2cm on the right and 1cm on the left in an inverted "Y" fashion) along the annular plane without incising to anterior mitral leaflet or extending incision into the left atrium. After the sufficient enlargement of the aortic root, a rectangular bovine pericardial patch was sewn in to enlarge the annulus, typically allowing a valve one to two sizes bigger than the native annulus to be implanted. RESULTS: The mean follow-up was 16.8 9.9 months. The incidence of re-exploration for bleeding and mortality was 0%. In this study, ARE during TEAVR was associated with an increased duration of cardiopulmonary bypass and cross clamp time (189.7 33.9 min and 140.1 23.8 min, respectively). CONCLUSIONS: We report our experience of TEAVR with ARE. It appears to be an excellent treatment option for avoiding PPM and also a useful tool for the management of future valve-in-valve transcatheter AVR patients. However, further studies are required to establish the safety and efficacy of this procedure.
CAPTION: Demographics, Perioperative and Postoperative Data "LEGEND": Top left: View of the operative field with the 2cm mini thoracotomy Top middle: Transverse aortotomy and exposure of the aortic valve Top right, bottom left: A vertical "Y" incision extended below the aortic annulus Bottom middle, right: Aortic valve replacement with aortic root enlargement


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