Totally Endoscopic Ascending Aortic Replacement and Mitral Valve Repair

We present totally endoscopic ascending aortic replacement (TEAAR) with concomitant mitral valve repair (Supplemental Video), successfully performed in a 50-year-old male patient presenting with exertional shortness of breath (New York Heart Association class II). Preoperative imaging revealed severe mitral regurgitation consistent with Carpentier type II pathology and an ascending aortic aneurysm measuring 46 mm. Although the ascending aortic diameter was 46 mm, replacement was performed due to concomitant severe mitral regurgitation, the patient’s young age, and institutional experience with endoscopic aortic surgery. These factors along with the patient’s preference supported addressing both pathologies in a single setting to avoid future operation.

Our operating setup was published previously. ¹ Once cardiopulmonary bypass (CPB) was initiated, the pericardium was opened and pericardial stay sutures were placed and externalized. The aorta was cross clamped with a Chitwood clamp, and Custodiol cold crystalloid cardioplegia was administered into the aortic root. The left atrium was opened. The ascending aorta was opened just proximal to the cross-clamp and resected just superior to the sinotubular junction. The appropriately sized Dacron graft was estimated according to the resected part of the ascending aorta. The proximal graft-to-aorta anastomosis was constructed using 2 running 4-0 polypropylene sutures in 2 layers. The distal graft-to-aorta anastomosis was also performed with 4-0 polypropylene sutures in a running fashion in 2 layers. For the mitral valve repair, the length of the neochords as well as the size of the annuloplasty ring were predicted based on preoperative transesophageal echocardiogram (TEE) measurements and confirmed during the operation. In our patient, 2 sets of 26 mm polytetrafluoroethylene (PTFE) SERAMON® CHORDAE LOOP (SERAG-WIESSNER, Naila, Germany) were inserted and secured at the head of the corresponding papillary muscle. Four PTFE SERAMON neochords were secured to the free edge of the flail segment of the mitral valve. A 36 mm annuloplasty ring (SimuForm Annuloplasty Ring, Medtronic, Dublin, Ireland) was then implanted. The left atriotomy was closed, and following deairing, the cross-clamp was removed. Total cross-clamp time was 120 min, and CPB time was 168 min. Times for procedural segments were as follows: proximal anastomosis was 30 min, distal anastomosis was 15 min, leaflet repair was 15 min, and annuloplasty ring implantation was 14 min. The postoperative TEE showed that there was trivial mitral regurgitation. The patient had an uneventful recovery and was discharged home on postoperative day 7.

TEAAR represents an emerging and technically demanding frontier in minimally invasive aortic surgery. Although minimally invasive aortic valve and mitral valve procedures have been progressively adopted, full endoscopic replacement of the ascending aorta remains exceedingly rare. ² This video report documents the successful application of TEAAR in combination with mitral valve repair.

The challenges inherent to TEAAR are substantial and include safe aortic exposure, mobilization, clamping, and control of both proximal and distal anastomoses within a confined endoscopic field. The totally endoscopic setting mandates precise anatomic orientation, advanced thoracoscopic skills and visualization, and meticulous control of bleeding. Hemostasis is particularly challenging at the distal anastomosis in a confined field; double-layer running sutures were used to reinforce sealing, and CPB allowed controlled visualization of bleeding sites. We believe this strategy is critical during the early learning curve.

The feasibility of TEAAR has been suggested in cadaveric models and porcine studies;³,⁴ however, its translation to routine clinical practice has been limited by technical difficulty, prolonged operative times, and concerns about hemostasis. Compared with a right anterior thoracotomy approach, the fully endoscopic technique avoids rib spreading, potentially reducing postoperative pain, length of stay, and infection rates.⁵ Recent multicenter series confirm the feasibility of endoscopic ascending aortic and root replacement with or without valve replacement but also underscore the steep learning curve and limited adoption to specialized centers. ²

TEAAR with mitral valve repair may be considered in younger patients with combined pathology, preserved ventricular function, and suitable thoracic anatomy. Contraindications include heavily calcified aortas, redo sternotomy, or poor endoscopic visualization.

In conclusion, TEAAR with mitral valve repair is technically feasible and safe but should currently be reserved for centers with significant endoscopic cardiac surgery expertise.