Endoscopically assisted selective antegrade cardioplegia in minimally invasive aortic valve replacement for patients with aortic insufficiency

Abstract

Objective: In minimally invasive aortic valve replacement via a right minithoracotomy for patients with significant aortic insufficiency, optimal cardioplegia delivery procedures remain controversial. This study aimed to describe and evaluate endoscopically assisted selective cardioplegia delivery in minimally invasive aortic valve replacement for aortic insufficiency.

Methods: Between September 2015 and February 2022, 104 patients (mean age, 66.0 ± 14.3 years) with moderate or greater aortic insufficiency underwent endoscopically assisted minimally invasive aortic valve replacement at our institutions. For myocardial protection, potassium chloride and landiolol were systemically administered before aortic crossclamping, and cold crystalloid cardioplegia was delivered selectively to the coronary arteries using step-by-step endoscopic procedures. The early clinical outcomes were also evaluated.

Results: Eighty-four patients (80.7%) had severe aortic insufficiency, and 13 patients (12.5%) had aortic stenosis and moderate or greater aortic insufficiency. A regular prosthesis was used in 97 cases (93.3%), and a sutureless prosthesis was used in 7 cases (6.7%). The mean operative, cardiopulmonary bypass, and aortic crossclamping times were 169.3 ± 36.5, 102.4 ± 25.4, and 72.5 ± 21.8 minutes, respectively. No patients underwent a conversion to full sternotomy or required mechanical circulatory support during or after surgery. No operative deaths or perioperative myocardial infarctions occurred. The median intensive care unit and hospital stays were 1 and 5 days, respectively.

Conclusions: Endoscopically assisted selective antegrade cardioplegia delivery is safe and feasible for treating minimally invasive aortic valve replacement in patients with significant aortic insufficiency.

Keywords: aortic insufficiency; aortic valve replacement; cardioplegia; endoscopic surgery; minimally invasive cardiac surgery.

Graphical abstract

Step-by-step selective antegrade cardioplegia delivery under endoscopic guidance.

Figure 1

The skin incision and thoracotomy position. Left: the anterior second intercostal approach for the vertical aorta. Right: the anterolateral third intercostal approach for the horizontal aorta. ICS, Intercostal space.

Figure 2

The cannulas used for delivering the cardioplegic solution. The cannula for RCA is slightly bent to match the angle of the RCA ostium. RCA, Right coronary artery; LCA, left coronary artery; LMT, left main trunk.

Figure 3

The step-by-step procedure for endoscopically assisted selective cardioplegia delivery. Step 1: The aortotomy is made without antegrade cardioplegia from the aortic root cannula after crossclamping. Step 2: The left hand grasps the suction tube to suck blood from the aortic root and lifts the aortic wall upward. With the endoscope on standby, the RCA cannula was grasped with the right hand and advanced into the aortic root. Step 3: The RCA ostia should be observed and engaged using endoscopy, and the cannula for the RCA should continue to lift the aortic wall upward, keeping the aorta open. Step 4: The cannula for the LCA is grasped in the left hand, and the LCA ostia is observed and engaged using an endoscope. It is examined whether both coronary artery cannulas are displaced using the endoscope. RCA, Right coronary artery; SOV, sinus of Valsalva; LCA, left coronary artery.

Figure 4

This study aimed to describe and evaluate endoscopically assisted selective cardioplegia delivery in minimally invasive AVR for AI. For myocardial protection, KCL and landiolol were systemically administered before aortic crossclamping, and cold crystalloid cardioplegia was delivered selectively to the coronary arteries using step-by-step endoscopic procedures. No operative deaths or perioperative myocardial infarctions occurred. Endoscopically assisted selective antegrade cardioplegia delivery is safe and feasible for treating minimally invasive AVR in patients with significant AI. AVR, Aortic valve replacement; AI, aortic insufficiency; KCL, potassium-chloride; RCA, right coronary artery; SOV, sinus of Valsalva; LCA, left coronary artery; ICU, intensive care unit.