Endoscopic aortic valve replacement with a contemporary telemanipulator system – drawbacks and limitations

Abstract

Aims: To date, aortic valve replacement is performed safely with a partial mini-sternotomy. However, a total endoscopic aortic valve replacement has not been performed. We established a stepwise approach for total endoscopic technique and to find out the limitations of the DaVinci telemanipulator system. Methods: The development of the endoscopic technique was divided into 6 steps including port placement and pericardiotomy, aortotomy, valve removal, suture placement, valve implantation, aortic closure. Between 11/2004 and 06/2006 a total of 65 patients received elective aortic valve replacement with partial/complete sternotomy and with at least 1, but not more than 4 telemanipulated steps during the surgical procedure. Results: In 61 patients the aorta was opened, in 62 the calcified valve was removed and the annulus debrided. In 12 patients the aorta was closed with running sutures. In 12 port-placement and pericardiotomy was performed. Here the limitations of the system became apparent. Mainly the outside construction of the DaVinci system resulted in major interference with the camera arm or opposite instrument arm. In 4 patients suture placement was performed. In 4 patients a conventional bioprosthesis was implanted with good access to the aortic annulus. All steps per se were performed in acceptable time frame with improvement of the technical skills. Conclusions: Endoscopic aortic valve replacement may be possible. However, the improvement of the telemanipulator systems, in particular a significant reduction of the outside dimensions, enhancement of the flexibility of the work and camera arms will tremendously improve the endoscopic access to the target structures.