Totally Endoscopic Aortic Valve Replacement Using a Longitudinal Incision for a Type 0 Bicuspid Aortic Valve: A Case Report

A 70-year-old man with severe aortic stenosis due to type 0 bicuspid aortic valve (BAV) (New York Heart Association (NYHA) class II) and mild aortic regurgitation (AR) underwent totally endoscopic aortic valve replacement (AVR) using a longitudinal aortotomy. Preoperative coronary angiography showed no obstructive coronary artery disease. A 29-mm bioprosthesis (INSPIRIS RESILIA, Edwards Lifesciences, Irvine, CA, USA) was implanted with a hybrid suture strategy (everting mattress at the nadirs plus interrupted sutures elsewhere). The longitudinal incision provided direct annular exposure, enabling implantation of a large prosthesis and facilitating annular circularization. Postoperative transthoracic echocardiography demonstrated an aortic valve area of 2.32 cm² with a mean pressure gradient of 6 mmHg and a maximum gradient of 11 mmHg, and no residual aortic regurgitation (no paravalvular or transvalvular components); physiologic intra-prosthetic washout jets may be present but are not classified as AR. Computed tomography on postoperative day (POD) 6 confirmed circular remodeling of the previously elliptical annulus. Recovery was uneventful, and the patient was discharged on POD 7. This case highlights the feasibility of an exposure-driven longitudinal aortotomy for totally endoscopic AVR in type 0 BAV and its potential role in annular remodeling; long-term durability requires further study.