Totally Endoscopic Aortic Valve Replacement With a Trifecta GT Bovine Pericardial Valve

The authors present a video showing their technique of totally endoscopic aortic valve replacement with a bovine pericardial valve (Trifecta GT, Abbott), performed for an 81-year-old patient with severe aortic stenosis and moderate aortic regurgitation. The patient was heavily symptomatic in class III and had a EuroSCORE II of 2.36. The patient was positioned supine on the operating table, with his right shoulder elevated by 30 degrees. Double lumen ventilation was also used.

The operation was performed through a 3 cm working incision in the second intercostal space parasternally, with two 10 mm ports in the second and fifth intercostal spaces in the anterior axillary line. The extra small Alexis wound protector was used in the working incision. A 3D 30-degree Karl Storz endoscope was inserted in the second intercostal port and the whole of the procedure was done under stereoscopic vision. The fifth intercostal port was used for the right-hand instruments during the opening of the pericardium and for the left atrial vent while the aorta was cross-clamped.

Three pericardial retraction sutures where used to retract the pericardium and the heart towards the endoscope (the sutures were externalized in the first, third, and seventh intercostal spaces in the middle axillary line).

The Chitwood cross-clamp was inserted through a separate hole in the first intercostal space, anterior and superior to the endoscope. On femoro-femoral cardiopulmonary bypass, the aorta was cross-clamped and Custodiol cardioplegia was used to arrest the heart. Half of the dose was given in the aortic root and the other half directly in the coronary ostia (due to the aortic regurgitation), after performing a transverse aortotomy 3 cm above the right coronary ostium. The heavily calcified valve was excised using long-shafted instruments, and the annulus was sized. A 23 mm Trifecta GT (Abbott) bovine pericardial prosthesis was inserted using 2/0 Ethibond sutures secured with the COR-KNOT® automated suture-fastening device. In order to facilitate the placement of the annular sutures, the authors used a self-expanded iron net to increase the volume of the aortic root.

The aortotomy was closed in two layers, the heart was de-aired, and the cross-clamp was removed. Postoperative transesophageal echocardiography confirmed a normally functioning prosthesis. The patient was extubated a couple of hours later and had an uneventful recovery.

Additional Resources

  1. Pitsis A, Tsotsolis N, Nikoloudakis N, et al. Totally endoscopic redo tricuspid valve repair. CTSNet. June 2019. doi: 10.25373/ctsnet.8199260.
  2. Pitsis A, Nikoloudakis N, Tsotsolis N, et al. Totally endoscopic bileaflet mitral valve repair with preformed chordae loops. CTSNet. March 2019. doi: 10.25373/ctsnet.7837853.
Dr Antonios Pitsis serves as a Proctor for Abbott.