Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery

Not All SAVR Are Created Equal: All the Approaches Available for Surgical Aortic Valve Replacement

Surgical Aortic Valve Replacement (SAVR) is still one of the pillars of cardiac surgery practice, and its role is evolving into a more complex operation. The competition with structural valve therapies and the urgent demand for less invasive solutions have unleashed surgeons' creativity in adapting to these new challenges. All the possible ways to surgically replace the aortic valve are analyzed in this review. Surgical techniques, advantages and disadvantages, and key differences are listed, helping surgeons navigate the available options. Sternotomy SAVR is the benchmark, but that is becoming obsolete and, in some cases, no longer performed for teaching purposes. Mini sternotomy is the easiest way to achieve minimal invasiveness in all anatomic situations, while right anterior thoracotomy is an elegant solution mastered by fewer surgeons. Endoscopic and robotic-assisted techniques are shaping the future of SAVR, yet they still lack wide adoption. The choice of approach is mainly dictated by the anatomic features of the patient and the surgeon's skills. A flow diagram to overcome the learning curve and advance toward more complex surgery is provided here. Mastering as many techniques as possible is paramount when offering a patient-tailored approach and performing a safe and less invasive operation.

Totally 3D endoscopic aortic valve replacement: initial results and experience from a single center

Objective

This study aimed to evaluate the feasibility and initial outcomes of totally endoscopic aortic valve replacement (TEAVR) performed via a single working port at the fourth intercostal space (ICS) utilizing a 3D endoscopic system.

Methods

A retrospective observational study was conducted on 35 consecutive patients who underwent TEAVR over a six-month period from December 2023 to June 2024. Patient selection was based on the presence of isolated aortic valve disease without the need for ascending aorta replacement or aortic root enlargement. A 4 cm single working port was created at the 4th ICS, extending from the right mid-axillary to the anterior axillary line. A 10-mm trocar for a 3D endoscope was placed at the right anterior-axillary line. Peripheral cardiopulmonary bypass (CPB) was established. The primary outcomes investigated included the success rate of the procedure, in-hospital mortality, and perioperative complications.

Results

The mean age of the patients was 58.7 ± 12.8 years, with 22.9% being female. The majority of patients (77.1%) presented with aortic stenosis, often accompanied by severe calcification. The medianCPB time was 210 ± 43 min, and the median aortic cross-clamp time was 132 ± 41 min. The procedure was successfully completed in all patients using the endoscopic approach, with no conversions to full sternotomy. Two mortalities were recorded, attributed to postoperative complications including bleeding and cerebral infarctions. The early (30-day) mortality rate was 5.7%. Prolonged mechanical ventilation (>48 h) was required in 17.1% of patients, and reoperation for bleeding was necessary in 2.9% of patients.

Conclusions

TEAVR is a feasible procedure with the potential to replace the traditional sternotomy approach for aortic valve replacement.