Totally endoscopic aortic valve replacement, TAVI and the art of war

‘The ultimate goal of warfare is to win without fighting’ Although, in its early years, cardiac surgery represented one of the most technologically advanced surgical specialties, inertia and lack of agency have struck the profession at its core. Contrary to other surgical specialties, such as general surgery, urology and gynaecology, which were keen to advance towards least-invasive operations, including laparoscopic and robotic procedures, cardiac surgeons have firmly resisted to partake in the hunt for the least-invasive approach to treat cardiac disease. Disheartening as it may be, cardiac surgeons have become notoriously slow to embrace innovation and adopt new techniques and technologies, therefore steadily disengaging from industry, which has directed its focus to catheter-based techniques. Alongside industry’s ample support, interventional cardiology has emerged as the patients' preference. In the span of a decade, transcatheter aortic valve implantation (TAVI) came to be the most disruptive cardiac intervention, rapidly altering the scene in the treatment of the aortic valve disease. Twenty-first century patients knowingly turn their back on sternotomy for routine coronary or structural interventions and tend to opt for alternatives, even if they are aware that the medium- and long-term outcomes of sternotomy-based treatments are significantly better. Patient preference and satisfaction define the new ‘battlefield’ of this war. Patients who are hesitant to agree to a sternotomy-based treatment for an aortic valve replacement (SAVR) may consider a minimally invasive approach as an alternative to TAVI, if the medium- and long-term outcomes of surgery are better. We already know that, compared to SAVR, TAVI has a worse all-cause mortality rate after 40 months and therefore should not be favoured for patients with long life expectancy [1]. The landscape further changes if we consider that we can produce the same or even better outcomes with surgical valves implanted through ports and a 2-cm single-finger working incision (totally endoscopic aortic valve replacement—TEAVR) through the use of new technologies and industry engagement. Today, we have an armamentarium of top-class technological equipment installed in our cardiac theatres and ready for broad use in TEAVR including 3D 4K endoscopes and monitors, robotic voice-controlled endoscopic camera holding arms, robotic surgical platforms, automated suturing devices, automated suture fastening devices, rapid deployment and sutureless valves and minimally invasive friendly conventional valves, both biological and mechanical. It would be foolish to dispute that the learning curve of these techniques is not steep. Thankfully, however, they are already being widely used and reproduced in leading centres across the globe. Besides Yilmaz and the Jena team whose experience in >200 cases is presented in this issue of EJCTS [2], there are more teams around the globe with more than a couple of hundred cases such as Vola and the Lyon team [3], Ito and the Tokyo team [4] and Pitsis and the Thessaloniki team [5]. Furthermore, we are fortunate to have a significant robotic TEAVR experience coming from across the Atlantic (Balkhy and the Chicago team) [6]. In the recent Techno-College meeting (EACTS annual meeting 2022, Milano), there were a live TEAVR procedure (performed by Pitsis et al.) and a live-in-a-box robotic TEAVR procedure (performed by Balkhy et al.). Both procedures are standardized and have proven to be reproducible as many teams around the globe have replicated the particular approaches in their departments. While the ‘war’ on AVR seems to be lost in the above 80-year-old age group and high-risk patients, there is still a battleground where surgery could excel, which is younger patients, patients with bicuspid pathology and patients with endocarditis. These are the patients to benefit from better medium- and long-term survival, less pacemaker implantations, ability to use both biological and mechanical prostheses and the ability to perform combined approaches. We should not forget that the use of mechanical prostheses is recommended by the European Association for Cardio-Thoracic Surgery guidelines for patients below the age of 60 years, as well as the use of both mechanical and biological prostheses for those aged 60–65 years [7]. TEAVR is considered the least-invasive approach for mechanical AVR. We need data to support that our TEAVR approaches, with or without the use of robotic equipment, have equal medium- and long-term results to sternotomy SAVR, but with significantly greater patient satisfaction, and we need to market these approaches and develop long-standing partnerships with industry. We have to choose our battlefield, which is the patients' mindsets. If general, Sun Tzu was alive today, he would advise us how to win this war without a fight but through: diplomacy (hybrid approaches with the interventional cardiologists, active participation in the heart teams); careful patient selection; engaging the industry and developing long-term partnerships; develop proctoring platforms to ease the learning curve; standardizing the approaches whether robotic or non-robotic TEAVR so that surgeons can easily copy/paste them; marketing the approaches in selected patients’ populations; developing large registries to produce hard evidence and benchmark studies; and actively participate in societies and associations with a special interest in TEAVR like the Endoscopic Cardiac Surgeons Club (ecsclub.org) and the International Society of Minimally Invasive Cardiothoracic Surgery (ismics.org). As Sun Tzu stated 2500 years ago: ‘opportunities multiply as they are seized’—we should not miss this opportunity!