Endoscopic Aortic Valve Replacement and Mitral Valve Replacement

The patient was a 72-year-old female who presented with exertional dyspnea. Transthoracic echocardiography revealed rheumatic changes involving both the aortic and mitral valves, with findings of severe aortic stenosis and moderate mitral regurgitation. 

The patient was positioned supine with a pillow placed behind her back to elevate the chest, and the right arm was lowered alongside her body. Peripheral cannulation was performed to establish cardiopulmonary bypass. A 5 cm incision was made in the right fourth intercostal space to serve as the main working port. A camera port was placed in the third intercostal space, adjacent to the working port. An additional 5 mm trocar was inserted at the fifth intercostal space to allow the assistant to introduce a suction device for enhanced visualization of the aortic valve. Two further incisions were made at the third and sixth intercostal spaces for the placement of the left atrial blade retractor and the venting catheter, respectively. 

Following pericardiotomy, the space behind the ascending aorta and above the right pulmonary artery was dissected to accommodate the Chitwood clamp. Traction sutures were placed on the aortic wall in preparation for aortic valve exposure. After aortic cross-clamping, the left atrium was opened, and a venting catheter was inserted. A C-shaped aortotomy was performed, and cardioplegia was delivered directly into the left main and right coronary arteries. The diseased aortic valve was excised, and annular calcifications were meticulously debrided using a rongeur. After thorough irrigation and suctioning, the annulus was sized appropriately. 

Attention was then turned to the mitral valve. The anterior leaflet was excised, leaving the posterior leaflet for chordal preservation. Annular sutures were placed starting at the posteromedial commissure to avoid sutures obstructing the view from the endoscope. A 29 mm bioprosthetic valve was implanted into the mitral position and secured using a Cor-Knot device. A venting catheter was then inserted into the left atrium, and the procedure continued with implantation of the aortic valve. Annular sutures were placed, and a 23 mm bioprosthetic valve was seated and secured with the Cor-Knot device. 

The aortotomy was closed in two layers, one side at a time, followed by closure of the left atrium. A venting catheter was placed in the ascending aorta for deairing, after which the Chitwood clamp was released. Hemostasis was confirmed, and the pericardium was reapproximated to complete the procedure. 

The patient's postoperative course was uneventful, and she was discharged home on postoperative day nine. 

References

1. 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.

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