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Totally Endoscopic Aortic Valve Repair: Technique, Early And Mid Term Outcomes
Olivera Rasovic, Luciana Benvegnų, Salvatore Poddi, Alessandro Favaro, Loris Salvador;
Cardiac Surgery Unit, Vicenza, Italy
BACKGROUND: Aortic valve repair (AVr) is a valid option for the treatment of aortic regurgitation (AR) but, due to its complexity, is not commonly performed through endoscopic approach. The aim of our study is to demonstrate the feasibility of totally endoscopic AVr in a experienced endoscopic Centre and describe its early and mid-term outcomes.
METHODS: We retrospectively reviewed 14 patients who underwent totally endoscopic AVr from 2019 to 2023.
Inclusion criteria were AR and absence of stenosis.
Baseline characteristics, intra-, post-operative and follow-up data were analyzed. Surgical technique was as follows: a 4 cm anterior right mini-thoracotomy through the II o III intercostal space as principal working port; three 5 mm mini-ports for the introduction of a 30-degree thoracoscope, aortic clamp and vent line. Cardiopulmonary Bypass (CPB) was achieved through femoro-femoral cannulation.
RESULTS: Median age was 53.5 years [Interquartile range (IQR) 23]; 13 patients were males (92.9%); 12 patients (85.7%) were pre-operatively on NYHA (New York Heart Association) class II, 2 (14.3%) on NYHA III; median Euroscore II was 0.8%; median pre-operative left ventricular ejection fraction was 60% (IQR 9). Concomitant procedures were 4 mitral valve repair (28.6%), 3 ascending aorta replacement (21.4%), 1 cryoablation (7.1%), 1 septal miectomy (7.1%), 1 resection of subaortic membrane (7.1%). Median cross-clamp time was 88 minutes (IQR 48). Median CPB time was 134.5 minutes (IQR 53). None needed a second cross-clamp. Median intensive care unit stay was 18 hours (IQR 24). AR at discharge was absent in 9 cases (64.3%), mild in 4 (28.6%), mild-moderate in 1 (7.1%). Median follow-up was 23 months (IQR 34). Survival at 1 year and at the last follow-up was 100%. At last follow-up AR was absent in 8 patients (57%), mild in 2 (14.3%), mild-moderate in 2 (14.3%), while 2 patients (14.3%) were reoperated for severe AVR, one at 4 years for recurrent endocarditis and one at 18 months for AVr failure.
CONCLUSIONS: In a high-volume Centre with experienced endoscopic surgeons totally endoscopic AVr is technically feasible and it provides satisfactory clinical and echocardiographic results at early follow-up. Mid-term outcomes are robust.
Mechanism of regurgitation and aortic repair technique| Mechanism of regurgitation (n patients, % of total) | Aortic repair techniques (n patients, % of total) |
| Degeneration of a tricuspid aortic valve (7 patients, 50%): cusps with perforation (1, 7.1%); prolapse (6, 42.9%); fenestrations (4, 28.6%); annular dilation (2, 14.3%); retraction and fibrosis of cusps (2, 14.3%) | Plicature of cusps, closure of fenestrations and perforations with a stitch in Gore-Tex, resuspension of the commissures (7, 50%). |
| Degeneration of a bicuspid aortic valve with a raphe of fusion (6 patients, 42.9%): fibrotic rafe retraction (4, 28.6%); perforation (1, 7.1%); fenestrations (1, 7.1%); prolapse (2, 14.3%) | Partial resection of the fibrotic raphe and resuspension of the commissures (3, 21.4%). Interposition of patch in heterologous pericardium in the fused cusp at the level of the raphe in order to reshape it, increasing its coaptation with the other cusp (2, 14.3%). Closure of perforation and fenestrations with a stitch in Gore-Tex and plicature of cusps (1, 7.1%). |
| Endocarditis with a cusp perforation (1, 7.1%). | Closure of cusp perforation with a patch of heterologous pericardium (1, 7.1%) |
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