Endoscopic Approach for Aortic Valve Replacement: Operative Results

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Objective: To describe our endoscopic aortic valve replacement (E-AVR) technique and to evaluate its operative results regardless of the type of prosthetic valve implanted in unselected patients. Methods: From July 2013 to June 2018, 158 consecutive patients (87 males, mean age 68.7±11.5 years, mean EuroScore II 1.54±1.31) underwent E-AVR. The surgical access was a 3-4 cm working port in the second right intercostal space with no-rib spreading and three additional 5 mm mini-ports for the introduction of a 30-degree thoracoscope, the Chitwood clamp and the vent line. Cardiopulmonary by-pass (CPB) was achieved through a femoro-femoral cannulation. Results: All patients underwent E-AVR. Associated procedures were 32 (20.2%): septal myectomy, mitral valve surgery, combined mitral and tricuspid valve repair and ascending aorta surgery in 8, 14, 2 and 8 cases respectively. Standard stented bioprosthesis were implanted in 71 cases, Rapid Deployment and Sutureless Bioprosthesis in 31 and 56 cases respectively. In isolated E-AVR, mean aortic cross clamp and CPB times were 87.5±22.1 and 126.1±28.4 minutes respectively and significant reduction was observed when a sutureless valve was implanted: 69.1±15.1 and 106.2±21.8 minutes (Sutureless) vs 93.2±15.1 and 135.5±21.8 minutes (Rapid Deployment) and 100.6±17.2 and 138.9±21.9 minutes (Stented). Mean ventilation, ICU time and hospital stay were 13.9±39.3 hours, 45.6±58.4 hours and 7.6±7.8 days respectively. Two patients died during hospitalization (1.26%). Re-exploration for bleeding and new permanent pacemaker implantation occurred in 5 (3.1%) and 6 (3.8%) cases respectively. No major neurologic events were observed. No paravalvular leakage was detected at discharge. One conversion to sternotomy occurred (0.6%). Conclusions: E-AVR is safe and feasible. The use of sutureless valve significantly reduces the aortic cross clamp and the CPB times. Concomitant procedures may be done through the same single working port. With further experience this approach may become the technique of choice for all patients undergoing AVR.

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