March 11th, 2014

French Surgeons Perform First Totally Endoscopic Aortic Valve Replacement

Surgeons in France report that they have performed the first totally endoscopic aortic valve replacement (TEAVR) in two human patients. Their paper has been published in the the Journal of Thoracic and Cardiovascular Surgery.

The new procedure may enable surgeons to replace the aortic valve without opening the chest, though it will still require cardiopulmonary bypass and resection of the old valve. The key to the new procedure is the recent availability of sutureless aortic valve bioprostheses, in this case  the Medtronic 3f Enable bioprosthesis. In recent years these devices have allowed surgeons to develop “minimally invasive” surgical techniques. The new report is about the first surgical procedure in which the chest is not opened and the procedure is performed entirely through endoscopes. The authors point out that one advantage of TEAVR is that it is very easy to convert to a more traditional open surgical procedure if it becomes necessary.

The two patients were 82 and 93 years of age and had aortic valve stenosis. The patients spent about 2 and 1/2 hours under cardiopulmonary bypass, but the actual implantation of the device took only 45 minutes. Both patients were discharged from the hospital in a week and have had no serious complications.

The authors say that the procedure times were “acceptable” and that they believe the learning curve for TEAVR could be shorter than for totally endoscopic bypass surgery. They further anticipate that advances in technology will lead to more efficient procedures.

The lead author of the paper, Marco Vola, a cardiovascular surgeon in Saint-Etienne, France, discussed the development of the procedure in a press release issued by the journal: “In our institution, we began by adopting the mini-sternotomy technique, involving a small incision through the sternum, as routine. We then transitioned to the right mini-thoracotomy approach, involving a small incision through the thorax, first under direct view, then with an endoscopic camera. Finally we adopted a totally endoscopic technique.”

“These first procedures show that totally endoscopic sutureless aortic valve replacement is technically feasible,” he said. “Further clinical experience and technical development are necessary to shorten operation times and to assess further the potential postoperative benefits of TEAVR.”

Catherine Otto, the co-chair of the writing committee for the new ACC/AHA valve guidelines, offered the following perspective on this new procedure:

The first description of a totally endoscopic sutureless aortic valve replacement in 2 elderly patients is another exciting development in potential options for treatment of severe symptomatic aortic stenosis. Compared to a standard surgical approach, a median sternotomy is not required although patients still require general anesthesia and an aortotomy for placement of the valve. Compared to transcatheter aortic valve implantation (TAVI), the endoscopic approach allows removal of the native calcified valve which might, in theory, reduce long term embolic rates or paravalvular regurgitation — although we have no data yet addressing these issues. On the other hand, the endoscopic procedure is more invasive than TAVI with several chest wall incisions and the aortotomy. If larger studies show that this approach to aortic valve replacement is effective with an acceptable mortality and morbidity, it will offer an intermediate option between standard surgical aortic valve replacement and transcatheter aortic valve implantation.


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