PITSIS TEAVR RAM updated 15 Feb 2020_edit.mp4 (766.14 MB)

Totally Endoscopic Aortic Valve Replacement Using an Automated Annular Suturing Device

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posted on 2020-03-24, 21:26 authored by Antonios Pitsis, Nikolaos Tsotsolis, Nikolaos Nikoloudakis, Timotheos Kelpis, Vassilis Economopoulos, Isaak Keremidis, Harisios Boudoulas, Konstantinos Dean Boudoulas

The case of a 73-year-old man in NYHA class 3 and a history of pulmonary edema, due to severe mixed aortic valve disease, is presented. The operation was performed with the authors’ totally endoscopic technique, which has been previously published on CTSNet (1). A 3D 30-degree Karl Storz endoscope was used. After the sizing of the aortic annulus, the authors placed 15 annular sutures using the RAM® 3.5 device. The RAM® device places a horizontal mattress, Teflon buttressed suture in one squeeze. The spacing of the two arms of the suture is 3.5 mm. A 5.0 mm model will become available in Europe in March 2020 (already FDA approved). The cassette of each individual suture is placed in the appropriate slot in a suture organizer. After finishing with the placement of all the annular sutures with the RAM® device, the authors use the SEW-EASY® device to place the sutures through the sewing cuff of the prosthesis. They used an Avalus (Medtronic) 25 mm valve. In order to ease the parachuting of the Avalus down to the aortic annulus, they used a cinching 4/0 Prolene suture, which was passed twice around the commissural posts of the Avalus. The cinching suture was cut and removed after the sutures had been secured using the COR-KNOT® device.

Postoperative TOE confirmed a well-functioning aortic prosthesis without any paravalvular leaks and a peak gradient of 11 mm Hg.

The authors believe that the use of automated suturing devices will greatly assist the spreading of the totally endoscopic technique for the treatment of the structural heart disease.


  1. Pitsis A, Tsotsolis N, Nikoloudakis N, Kelpis T, Economopoulos V, Keremidis I. Totally endoscopic aortic valve replacement with a Trifecta GT bovine pericardial valve. CTSNet. August 2019. doi:10.25373/ctsnet.9587900.
  2. Pitsis A, Tsotsolis N, Nikoloudakis N, Economopoulos V, Kelpis T. Totally endoscopic redo tricuspid valve repair. CTSNet. June 2019. doi:10.25373/ctsnet.8199260.
  3. Pitsis A, Nikoloudakis N, Tsotsolis N, Economopoulos V, Kelpis T, Keremidis I, et al. Totally endoscopic bileaflet mitral valve repair with preformed chordae loops. CTSNet. March 2019. doi:10.25373/ctsnet.7837853.
  4. Pitsis A, Tsotsolis N, Nikoloudakis N, Economopoulos V. Totally endoscopic mitral valve repair with predetermined length of synthetic chordae. CTSNet. November 2019. doi:10.25373/ctsnet.10070126.


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