Totally 3D Endoscopic Minimally Invasive Double Valve Procedure

A 79-year-old female presented with dyspnea. She had a history of interstitial pneumonia on oral steroid therapy. Further workup revealed severe mitral regurgitation from the anterior leaflet and severe central aortic regurgitation. She was a high-risk candidate with EuroScoreⅡ 6.6 %. She was considered as a totally endoscopic MICS candidate for aortic valve replacement and mitral valve repair.

The patient was placed in thirty-degree left lateral decubitus position with the right arm fixed over the head. A 10-mm trocar for a 3D-endoscope (Karl Storz, Tuttlingen, Germany) was inserted through the third intercostal space on the right mid-axillary line. A main 4-cm incision was made at the fourth intercostal space without rib-spreading. A 1.5-cm incision for left-handed (second) instruments was placed at the second intercostal space on the right anterior axillary line. Soft tissue retractors were applied on each of the main and second ports. Femoral-femoral cardiopulmonary bypass was established with a two-stage venous cannula for venous drainage. The patient’s heart was arrested with antegrade and retrograde cardioplegia. The Ascending aorta was cross-clamped with a flexible clamp through the second window and cardiac arrest was achieved with antegrade and retrograde cardioplegia. Through a left atrial incision, we observed a perforation of the anterior mitral leafl et. We placed polypropylene sutures to close the perforation and placed a partial band for mitral annuloplasty with Physio Flex (Edwards Lifescience, Irvine CA, U.S.A.).

After pressure-testing the repair with saline injection to left ventricle, we made an aortotomy towards left-non commissure and exposed the aortic valve with two commissural stay sutures. The aortic leaflets were excised, and annulus size was measured with sizers for 21-mm Inspiris (Edwards Lifescience) pericardial valve. The bioprosthesis was placed in intra-annular position. The aorta was closed with two-layer polypropylene sutures. The patient was successfully weaned off CPB. Transesophageal echocardiography demonstrated no mitral regurgitation or paravalvular leakage. Aortic cross-clamp time, CPB time and operation time were 107, 143 and 202 minutes, respectively. The patient was extubated in 19 hours. She was transferred to the floor 46 hours after the surgery. She had an uneventful recovery and was discharged to home on postoperative day 7. Transthoracic echocardiogram showed well functioning aortic and mitral valves without leakage at the time of discharge.

References

1. Tokoro M, Sawaki S, Ozeki T, Orii M, Usui A, Ito T. Totally endoscopic aortic valve replacement via an anterolateral approach using a standard prosthesis. Interact Cardiovasc Thorac Surg. 2020 Mar 1;30(3):424-430.

2.Hosoba S, Ito T, Zaikokuji K. A novel ‘two-window’ technique to facilitate totally 3D-endoscopic mitral valve repair. Surg Today. 2019 Epub Nov 29.