Endoscopic off-pump aortic valve replacement: does the pericardial cuff improve the sutureless closure of left ventricular access?

Abstract

The occluder is easy to use and the pericardial cuff dramatically increases its efficacy as demonstrated by a significant reduction of blood loss. The cuffed occluder opens the way for endoscopic, off-pump, transventricular aortic valve replacement.

Towards no-scar cardiac surgery — minimally invasive access through umbilicus for aortic valve replacement

“…In the in vitro test, 1-min flow-through was 2860 AE 176 ml for the standard occluders and 348 AE 56 ml for preclotted occluders ( p < 0.001) with a flow reduction by a ratio of 8.2 -similarly to the decrease in blood loss by a ratio of 9.4 when using a pericardial cuff, as reported by Tozzi et al [3].…”

“…Baseline mean blood pressure was 61 AE 15 mmHg, it decreased to 52 AE 10 mmHg during deployment and remained stable at 64 AE 12 mmHg after the procedure. Precise measurements of blood loss with standard occluders were performed by Tozzi et al previously and were found to be 800 AE 20 ml in 3 h (100 AE 5 ml in 3 h when using a pericardial cuff) [3] and were not repeated, blood loss with preclotted occluders was 100 AE 30 ml in 1 h ($80 ml during deployment).…”

“…A window of at least 3 Â 4 cm was created in the pericardium and the apex of the heart was visualised (Video 1). From this point, the procedure of gaining trans-apical access and closing it using a 12-mm Amplatzer occluder for interventricular septal defect closure (Aga, Golden Valley, MN, USA) is described in detail in Tozzi et al [3]. In brief, it was as follows: after heparin injection (100 IU kg À1 ), under fluoroscopic control, we punctured the heart, positioned a guide wire and inserted a 30F sheath through the tunnel and the cardiac apex, into the left ventricle, simulating the approach for aortic valve replacement.…”

“…The limiting factor for this procedure to become even less invasive is the closure of left ventricular defect after catheter withdrawal. It has been reported previously that repair of the left ventricle with a standard sutureless closing device in a thoracoscopic fashion is feasible [3]. The goal of this study is to prove that distant singleorifice, single-channel access is sufficient to perform a transapical valve replacement procedure, which would be a major leap towards no-scar cardiac surgery.…”

“…As the use of a standard occluder was shown previously to be associated with increased blood loss during the procedure [3], as a side task we decided to test preclotting of the occluder with non-heparinised blood to minimise blood loss during the procedure.…”