Totally endoscopic aortic valve replacement: Techniques and early results

Figures

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  Figure 1. The patient was positioned supine with the right hemithorax elevated 20–30 degrees, the right upper limb was placed parallel to the body, and the elbow joint was slightly flexed.

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  Figure 2. Setup of the working ports. Main working port: 3–4 cm in length, for patients with aortic valve insufficiency, the main working port was located between the midclavian line and anterior axillary line of the right 3rd intercostal space (ICS); in patients with aortic valve stenosis (AS), the main operating port was located between the parasternal line and the midclavicular line of the right 3rd ICS; mainly used for primary surgical instruments and delivery of cardioplegia. Auxiliary working port: 1.5–2 cm in length, located between the anterior axillary line and the midaxillary line of the 3rd ICS, mainly used for placing a CHITWOOD aortic cross-clamp, a catheter for left ventricular venting, and instruments operated by the surgeon's left hand. Camera port: 1–1.5 cm in length, located between the 4th ICS between the anterior axillary line and the midaxillary line.

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  Figure 3. Main steps of total endoscopic aortic valve replacement. (1) Incision on ascending aorta. (2) The aortic incision was extended toward the right/left commissural on the left side and to the non-coronary sinus near the left/non-commissural on the right side. A stitch was placed at the center of the superior edge, and two stitches were placed at the inferior edge of the aortic incision. (3) Resection of the aortic leaflets. (4) 2–0 polyester stitches with pledges were used for intermittent sutures of the prosthesis. (5) Seating the prosthesis valve. (6) Knotting could be done in the order of first non-coronary annulus, then left coronary annulus, and finally right coronary annulus with a unique minimally invasive knot pusher. (7) Remove the stitches in the same previous order. (8) Check the status of the prosthesis. (9) Close the aortic incision.