For aortic valve replacement, cardiovascular surgeons usually have to make a large cut in the patient's chest. But this may be a thing of the past; for the first time, surgeons in France have successfully replaced the aortic valve in two patients without opening their chest during surgery.
A study detailing the procedure, carried out using totally endoscopic aortic valve replacement (TEAVR), has been published in the Journal of Thoracic and Cardiovascular Surgery.
The researchers, led by Dr. Marco Vola of the Department of Cardiovascular Surgery at the Centre Hospitalier Universitaire de Saint-Etienne in France, say their findings show that TEAVR has the potential to improve the quality of life for heart patients by reducing chest trauma.
Cardiovascular surgeons already use endoscopic surgery for many heart procedures, including coronary artery bypass grafting and atrial septal defect repair.
Compared with other methods, endoscopic surgery leads to faster recovery time for patients and is less painful, meaning their quality of life after the procedure is improved.
How was the TEAVR procedure carried out?
The research team says that until now, using TEAVR had not been feasible as the required stented tissue valves were not available.
The picture above shows each step of the TEAVR procedure. Surgeons were able to use the technique to replace the aortic valve of two patients without having to open their chest during surgery.
Image credit: American Association for Thoracic Surgery
But the recent introduction of sutureless bioprostheses for aortic valves that are mounted on a compressible self-expanded nitinol (nickel titanium) stent allowed the surgeons to carry out the procedure.
Explaining how the surgeons completed the aortic valve replacement in each patient, Dr. Vola says they began by using the mini-sternotomy technique. This involves a small incision through the sternum (breastbone).
They then carried out a mini-thoractomy, involving a small incision through the throrax. The surgeons did this under direct view before changing to the use of an endoscopic camera. The rest of the procedure, which included the implantation of the stent, was done using a totally endoscopic technique.
"It is important to note that when performing TEAVR, a quick and safe conversion to mini-thoracotomy under direct view can be made if circumstances demand. This would still offer significantly reduced chest trauma," explains Dr. Vola.
The procedure took less than 45 minutes for each patient.
The future of TEAVR
The investigators note that when testing totally endoscopic surgery in other fields, the procedure involved longer cardiopulmonary bypass (CBP) time. CBP involves a patient being connected to a machine that temporarily takes over the function of their heart and lungs during surgery.
Furthermore, totally endoscopic surgery increased the amount of time an aortic cross-clamp was used - a surgical instrument that clamps the aorta and separates the systemic circulation from the outflow of the heart.
But the researchers say they believe longer CBP and clamping time is acceptable and that the testing periods for TEAVR could be shorter than the testing period reported for totally endoscopic coronary artery bypass grafting.
However, there is still a way to go before TEAVR is a widely used surgical procedure for heart patients.
The investigators say improvements to the technique are required, including the development of second-generation sutureless bioprostheses to simplify implantation.
But Dr. Vola says the team's findings show that TEAVR is "technically feasible." He adds:
"Further clinical experience and technical development are necessary to shorten operation times and to assess further the potential postoperative benefits of TEAVR."