Totally Endoscopic Aortic Valve and Ascending Aorta Replacement

A 57-year-old man presented with a two-year history of progressively worsening exertional dyspnea. Computed tomography revealed a 50 mm fusiform ascending aortic aneurysm. Echocardiography showed a heavily calcified bicuspid aortic valve with severe stenosis (peak/mean gradient 87/60 mmHg, aortic valve area 0.6 cm²) and preserved left ventricular ejection fraction (55 percent).

Surgical Technique

       1. Establishing the Working Ports

A totally endoscopic approach was performed using three intercostal ports. The main working port (3–4 cm) was placed in the right third intercostal space between the parasternal and midclavicular lines. The auxiliary port (1.5–2 cm) was positioned at the third intercostal space along the anterior to midaxillary line, and the camera port (1–1.5 cm) was located at the fourth intercostal space.

       2. Cardiopulmonary Bypass and Exposure

Percutaneous cardiopulmonary bypass was established via the femoral vessels. The pericardium was opened and suspended for optimal exposure. Left ventricular venting was achieved through the superior pulmonary vein. Antegrade cardioplegia was administered, and the aorta was cross-clamped using a Chitwood clamp.

       3. Aortic Resection and Valve Exposure

The ascending aorta was transected approximately 2 cm above the sinotubular junction and approximately 2 cm distal to the cross-clamp. Retraction sutures were placed to optimize visualization.

       4. Aortic Valve Replacement

The diseased valve was excised and replaced with a bioprosthetic valve using interrupted, pledgetless sutures secured with a Cor-Knot device.

       5. Ascending Aortic Replacement

Proximal and distal anastomoses were performed with Teflon reinforcement, along with additional posterior sutures and Bioglue to ensure hemostasis.

       6. Completion

After deairing, the cross-clamp was removed, hemostasis confirmed, and the patient was weaned from bypass.

Postoperative Outcomes

Recovery was uneventful, with six hours of ventilation, two days in the intensive care unit (ICU), discharge on day four, and no complications at the seven-month follow-up.

References

1. Viet Chuong PT, Thuan PQ, Thang HD, Huy LD, Bao Luan TM, Dinh NH. Totally endoscopic replacement of the ascending aorta with 3-dimensional visualization: Defining “totally endoscopic?” A case report. JTCVS Tech. 2025 Mar 5;31:45-48. doi:10.1016/j.xjtc.2025.02.010. PMID:40641788; PMCID:PMC12237750.
2. Hosoba S, Ito T, Mori M, Kato R, Kajiyama K, Maeda S, Nakai Y, Morishita Y. Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery. Ann Thorac Surg. 2023 Oct;116(4):744-749. doi:10.1016/j.athoracsur.2023.04.045. Epub 2023 Jun 3. PMID:37276923.

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