Totally Endoscopic Aortic Valve Replacement with Concomitant Trans-Aortic Mitral Valve Repair for Mitral Regurgitation

Totally Endoscopic Aortic Valve Replacement with Concomitant Trans-Aortic Mitral Valve Repair for Mitral Regurgitation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case report Totally Endoscopic Aortic Valve Replacement with Concomitant Trans-Aortic Mitral Valve Repair for Mitral Regurgitation Antonios Pitsis, Nikolaos Tsotsolis, Harisios Boudoulas, Konstantinos Dean Boudoulas This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-102684/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Oct, 2021 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract Background Minimally invasive aortic valve procedures through a hemi-sternotomy or a right anterior mini-thoracotomy have gained popularity over the last several years. Totally endoscopic aortic valve replacement (TEAVR) is an innovative and a less invasive (incision-wise) surgical aortic valve replacement (SAVR) technique. The operative steps of TEAVR have been reported previously from our group. Mitral regurgitation (MR) frequently accompanies aortic valve disease, and sometimes requires repair. Can totally endoscopic surgery be applied in such cases? Case presentation We present the surgical technique of a totally endoscopic approach to aortic valve replacement and concomitant mitral valve repair for primary or secondary MR. We used the aortotomy incision and avoided an atriotomy that would result in a prohibited increase in cross-clamp (XC) and cardiopulmonary bypass (CPB) times and an elevation in mortality and morbidity rates. Neochords (artificial chordae tendineae) were used for the repair of primary MR and the edge-to-edge approach was used for the repair of secondary MR. Conclusion Totally endoscopic aortic valve replacement and concomitant mitral valve repair can be performed transaortically with reasonable XC and CPB times, and excellent short-term results. Cardiothoracic Surgery minimally invasive cardiac surgery totally endoscopic aortic valve replacement totally endoscopic mitral valve repair edge-to-edge repair trans-aortic mitral valve repair Figures Figure 1 Figure 2 Introduction While endoscopic mitral and tricuspid valve procedures have become a first line treatment in many centers globally, this is not the case for the aortic valve. Minimally invasive aortic valve replacement or repair, usually is performed through a hemi-sternotomy or through a right anterior mini-thoracotomy. The operative steps of totally endoscopic aortic valve replacement (TEAVR), which is the routine practice at St. Luke’s Hospital, Thessaloniki, Greece, has been performed for over a year with more than 100 cases completed [ 1 ]. TEAVR is a less invasive (incision-wise) approach, associated with shorter intensive care time and hospital length of stay, and allows patients to return to work earlier compared to classical surgery; however, it is associated with prolonged XC and CPB times, especially during the learning curve of this approach, albeit steep [ 1 ]. Primary MR (approximately 3%) or secondary MR (approximately 10%) may be associated with aortic valve disease, particularly in patients with bicuspid aortic valves or in patients with CAD, respectively. In these cases, mitral valve repair can be performed via an aortotomy via a trans-aortic approach simultaneously with TEAVR, thus avoiding an atriotomy that would result in an increase in XC and CPB times. Here we present our technique of TEAVR and concomitant trans-aortic mitral valve repair for primary or secondary MR. In cases with primary MR (Video 1), artificial chordae tendineae were used to repair the prolapsing/flail mitral valve in which the length was calculated preoperatively by transesophageal echocardiography (TEE), as previously reported [ 2 ]. In cases of secondary MR (Video 2), the edge-to-edge repair method was used [ 3 ]. Written informed consents for publication of their clinical details and clinical images were obtained from the patients. Copies of the consent forms are available for review by the Editor of this journal. Case Presentation This endoscopic approach is performed through a 3 cm right parasternal working incision in the 2nd intercostal space (ICS) and a 10 mm port for the 3D 30 degrees Karl Storz endoscope in the same ICS laterally, anterior to the right anterior axillary line [ 1 ]. An extra-extra small Alexis soft tissue protector is deployed through the incision. On full CPB from the groin, the Chitwood clamp is inserted through a separate stab wound incision (3 mm) in the 1st ICS, cephalad to the port of the endoscope, and Custodiol cold crystalloid cardioplegia is given in the aortic root, or directly to the coronary ostia in cases of aortic regurgitation. After the heart is arrested, a right superior pulmonary vein vent is inserted through a separate stab wound incision (3 mm) in the 5th ICS, anterior axillary line. A transverse aortotomy is opened proximal to the fat body of the aorta (3 cm distal to the right coronary artery), the diseased aortic valve is excised and the annulus is debrided and washed. A metal net spreader (Fehling Instruments, DE) is inserted inside the aortic annulus to facilitate exposure of the mitral leaflets. In cases of secondary MR, a horizontal mattress, teflon buttressed PTFE suture is used to perform an edge-to-edge repair between A2 and P2 using a deep bite of at least 5 to 7 mm (see Fig. 1a and 1b, and Video 2). In cases of primary MR, a second metal net is inserted inside the first one and at the level of the anterior mitral leaflet (see Fig. 2a and Video 1). A prefabricated set of the pre-measured length of PTFE neochords (Seramon chordae loop, Serag Wiessner, DE) are inserted and secured at the fibrous head of the corresponding papillary muscle (Fig. 2b and 2c). The open end of the loops (neochords) are then secured to the free edge of the prolapsing/flail segment of the mitral leaflet (Fig. 2d). Several loops 4 to 5 mm apart in the prolapsing segments are used in order to spread the leaflet tension and to improve the durability of the repair. This type of repair is only applicable for anterior leaflet prolapse (1 out of the first 100 TEAVRs in our experience) and middle scallop (P2) posterior leaflet prolapse (2 out of the first 100 TEAVRs in our experience). Prolapse/flail of the anterolateral (P1) and posteromedial (P3) scallops, and of the two commissures, cannot be repaired with the trans-aortic approach, because these segments are well hidden by the anterior leaflet and its chords. Also marked dilation of the mitral annulus is a relative contradiction of this technique (better managed with an atriotomy in order to perform an annuloplasty). Alternatively, the loop technique with the edge-to-edge approach can be combined to achieve a watertight mitral valve through the trans-aortic approach, but so far, we have not performed this type of repair. Finally, we proceed with the aortic valve replacement with a conventional mechanical or biological prostheses, as previously described by our group.[ 1 ] XC and CPB times for the combined approach is reasonable (below 90 and 120 minutes respectively for primary MR and below 60 and 90 minutes respectively for secondary MR, after the initial learning curve of the technique). Short term follow-up (mean 5,66 months, range: 0,93 − 9,9) of our 13 patients operated with the described technique have been excellent with MR ≤ 1+ (mild). Discussion And Conclusion Totally endoscopic approaches will increasingly become more popular in the years to come. A successful surgical technique of TEAVR and concomitant totally endoscopic mitral valve repair via a trans-aortic approach is presented. When stand-alone endoscopic mitral repair is performed, this is usually done through a more lateral thoracotomy incision through the 4th ICS [ 2 ]. In order to perform a combined aortic valve replacement and a mitral repair through a standard left atriotomy incision, we can place our working incision through the 3rd ICS in the middle clavicular line, which is a compromise for both the endoscopic aortic valve replacement and the mitral repair through a left atriotomy. Such an approach will make the placement of the aortic annular sutures more difficult, due to the fact that the working incision is not aligned with the aortic annulus, and will prolong the XC time in excess of 120 min and the CPB time in excess of 180 min. The aortotomy mitral repair approach presented here, significantly shortens the XC and CPB time to 90 min and 120 min respectively for primary MR and to 60 min and 90 min respectively for secondary MR, thus making it possible to perform double valve (aortic and mitral) totally endoscopic surgery within reasonable XC and CPB time which are comparable to median sternotomy approaches. Contraindications of the presented technique are: a) marked mitral annular dilation - better managed with an annuloplasty procedure through a left atriotomy [ 4 ] and b) P1 or P3 or commissural flail/prolapse - better managed with the loop technique through a left atriotomy [ 2 , 4 ] (through a median sternotomy incision if combined with aortic valve disease). The presented method substantially decreases intensive care times and hospital length of stay, and allows patients to return to work earlier. It should be mentioned that the need for simultaneous aortic and mitral valve surgery is not uncommon, since anterior leaflet prolapse can be found in patients with bicuspid aortic valve [ 5 ]. Abbreviations TEAVR: totally endoscopic aortic valve replacement SAVR: surgical aortic valve replacement XC: cross clamp CPB: cardiopulmonary bypass MR: mitral regurgitation TEE: transesophageal echocardiography ICS: intercostal space Declarations Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on request. Funding No source of funding was used in the preparation of this manuscript. Contributions AP-concept/design, writing of manuscript, NT-data collection, HB-critical revision of article, KDB-critical revision of article. All authors read and approved the final manuscript. Ethics declarations Ethics approval and consent to participate Not applicable. Consent for publication All patients involved provided written consent to use clinical information for scientific publications. Competing interests AP is a consultant for teaching and training for Abbott, Medtronic, LSI SOLUTIONS. NT, HB, KDB have no competing interests. Acknowledgements We wish to thank Mr. Isaak Keremidis, perfusionist, for his assistance with data collection. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. References Pitsis, A., H. Boudoulas, and K.D. Boudoulas, Operative steps of totally endoscopic aortic valve replacement. Interact Cardiovasc Thorac Surg, 2020. 31 (3): p. 424. Pitsis, A., et al., Preoperative determination of artificial chordae tendineae length by transoesophageal echocardiography in totally endoscopic mitral valve repair. Interact Cardiovasc Thorac Surg, 2020. 31 (1): p. 20-27. Maisano, F., et al., The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg, 1998. 13 (3): p. 240-5; discussion 245-6. Pitsis, A., et al., Mitral valve repair: moving towards a personalized ring. J Cardiothorac Surg, 2019. 14 (1): p. 108. Boudoulas, K.D., et al., Floppy mitral valve/mitral valve prolapse: A complex entity with multiple genotypes and phenotypes. Prog Cardiovasc Dis, 2020. 63 (3): p. 308-326. Supplementary Files CAREchecklistEnglishAP.pdf Video1JCTS.mp4 Video 1: a case of severe aortic stenosis and severe mitral regurgitation due to a flail P2; the loop technique (4 neochords to P2) was used trans-aortically with a totally endoscopic approach. Video2JCTS.mp4 Video 2: a case of severe aortic stenosis and severe mitral regurgitation due to a dilated cardiomyopathy and tethering of both the anterior and posterior leaflets; the edge-to-edge technique was used trans-aortically with a totally endoscopic approach. Cite Share Download PDF Status: Published Journal Publication published 30 Oct, 2021 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Minor revision 14 Aug, 2021 Reviewer # 3 agreed at journal 06 Apr, 2021 Review # 2 received at journal 20 Dec, 2020 Review # 1 received at journal 20 Dec, 2020 Reviewer # 2 agreed at journal 02 Dec, 2020 Reviewer # 1 agreed at journal 29 Nov, 2020 Reviewers invited by journal 28 Nov, 2020 Editor assigned by journal 01 Nov, 2020 Submission checks completed at journal 01 Nov, 2020 Editor invited by journal 01 Nov, 2020 First submitted to journal 29 Oct, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-102684","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":4469750,"identity":"dd5b7556-7182-4078-afba-ca21aa546a83","order_by":0,"name":"Antonios 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P2.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-102684/v1/668037b36edd173be3fb89da.jpg"},{"id":15050679,"identity":"8d71164e-b493-465e-9010-e1fb8adf3693","added_by":"auto","created_at":"2021-10-30 11:55:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":682266,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-102684/v1/c89c9e2a-46ae-4fb4-a7eb-f04486978cb9.pdf"},{"id":3489876,"identity":"b06a1e35-adcd-4ff7-b1c6-945299aca2ae","added_by":"auto","created_at":"2020-11-10 15:16:05","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":647925,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglishAP.pdf","url":"https://assets-eu.researchsquare.com/files/rs-102684/v1/07dd7e69466dffdb7d699cb4.pdf"},{"id":3489878,"identity":"c7189aee-7a46-44f8-8467-c0ecae33f9cc","added_by":"auto","created_at":"2020-11-10 15:16:08","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":112388637,"visible":true,"origin":"","legend":"Video 1: a case of severe aortic stenosis and severe mitral regurgitation due to a flail P2; the loop technique (4 neochords to P2) was used trans-aortically with a totally endoscopic approach.","description":"","filename":"Video1JCTS.mp4","url":"https://assets-eu.researchsquare.com/files/rs-102684/v1/9dc43068503869e0d6cb5ed1.mp4"},{"id":3489879,"identity":"2015ef5a-7a31-4dba-ad10-60091bac4f12","added_by":"auto","created_at":"2020-11-10 15:16:10","extension":"mp4","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":134195596,"visible":true,"origin":"","legend":"Video 2: a case of severe aortic stenosis and severe mitral regurgitation due to a dilated cardiomyopathy and tethering of both the anterior and posterior leaflets; the edge-to-edge technique was used trans-aortically with a totally endoscopic approach.","description":"","filename":"Video2JCTS.mp4","url":"https://assets-eu.researchsquare.com/files/rs-102684/v1/fe4372a2378d09091d35c7a4.mp4"}],"financialInterests":"","formattedTitle":"Totally Endoscopic Aortic Valve Replacement with Concomitant Trans-Aortic Mitral Valve Repair for Mitral Regurgitation","fulltext":[{"header":"Introduction","content":" \u003cp\u003eWhile endoscopic mitral and tricuspid valve procedures have become a first line treatment in many centers globally, this is not the case for the aortic valve. Minimally invasive aortic valve replacement or repair, usually is performed through a hemi-sternotomy or through a right anterior mini-thoracotomy. The operative steps of totally endoscopic aortic valve replacement (TEAVR), which is the routine practice at St. Luke\u0026rsquo;s Hospital, Thessaloniki, Greece, has been performed for over a year with more than 100 cases completed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTEAVR is a less invasive (incision-wise) approach, associated with shorter intensive care time and hospital length of stay, and allows patients to return to work earlier compared to classical surgery; however, it is associated with prolonged XC and CPB times, especially during the learning curve of this approach, albeit steep [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Primary MR (approximately 3%) or secondary MR (approximately 10%) may be associated with aortic valve disease, particularly in patients with bicuspid aortic valves or in patients with CAD, respectively. In these cases, mitral valve repair can be performed via an aortotomy via a trans-aortic approach simultaneously with TEAVR, thus avoiding an atriotomy that would result in an increase in XC and CPB times.\u003c/p\u003e \u003cp\u003eHere we present our technique of TEAVR and concomitant trans-aortic mitral valve repair for primary or secondary MR. In cases with primary MR (Video 1), artificial chordae tendineae were used to repair the prolapsing/flail mitral valve in which the length was calculated preoperatively by transesophageal echocardiography (TEE), as previously reported [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In cases of secondary MR (Video 2), the edge-to-edge repair method was used [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWritten informed consents for publication of their clinical details and clinical images were obtained from the patients. Copies of the consent forms are available for review by the Editor of this journal.\u003c/p\u003e "},{"header":"Case Presentation","content":"\u003cp\u003eThis endoscopic approach is performed through a 3\u0026nbsp;cm right parasternal working incision in the 2nd intercostal space (ICS) and a 10\u0026nbsp;mm port for the 3D 30 degrees Karl Storz endoscope in the same ICS laterally, anterior to the right anterior axillary line [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. An extra-extra small Alexis soft tissue protector is deployed through the incision. On full CPB from the groin, the Chitwood clamp is inserted through a separate stab wound incision (3\u0026nbsp;mm) in the 1st ICS, cephalad to the port of the endoscope, and Custodiol cold crystalloid cardioplegia is given in the aortic root, or directly to the coronary ostia in cases of aortic regurgitation. After the heart is arrested, a right superior pulmonary vein vent is inserted through a separate stab wound incision (3\u0026nbsp;mm) in the 5th ICS, anterior axillary line. A transverse aortotomy is opened proximal to the fat body of the aorta (3\u0026nbsp;cm distal to the right coronary artery), the diseased aortic valve is excised and the annulus is debrided and washed. A metal net spreader (Fehling Instruments, DE) is inserted inside the aortic annulus to facilitate exposure of the mitral leaflets.\u003c/p\u003e\n\u003cp\u003eIn cases of secondary MR, a horizontal mattress, teflon buttressed PTFE suture is used to perform an edge-to-edge repair between A2 and P2 using a deep bite of at least 5 to 7\u0026nbsp;mm (see Fig.\u0026nbsp;1a and 1b, and Video 2). In cases of primary MR, a second metal net is inserted inside the first one and at the level of the anterior mitral leaflet (see Fig.\u0026nbsp;2a and Video 1). A prefabricated set of the pre-measured length of PTFE neochords (Seramon chordae loop, Serag Wiessner, DE) are inserted and secured at the fibrous head of the corresponding papillary muscle (Fig.\u0026nbsp;2b and 2c). The open end of the loops (neochords) are then secured to the free edge of the prolapsing/flail segment of the mitral leaflet (Fig.\u0026nbsp;2d). Several loops 4 to 5\u0026nbsp;mm apart in the prolapsing segments are used in order to spread the leaflet tension and to improve the durability of the repair. This type of repair is only applicable for anterior leaflet prolapse (1 out of the first 100 TEAVRs in our experience) and middle scallop (P2) posterior leaflet prolapse (2 out of the first 100 TEAVRs in our experience). Prolapse/flail of the anterolateral (P1) and posteromedial (P3) scallops, and of the two commissures, cannot be repaired with the trans-aortic approach, because these segments are well hidden by the anterior leaflet and its chords. Also marked dilation of the mitral annulus is a relative contradiction of this technique (better managed with an atriotomy in order to perform an annuloplasty). Alternatively, the loop technique with the edge-to-edge approach can be combined to achieve a watertight mitral valve through the trans-aortic approach, but so far, we have not performed this type of repair.\u003c/p\u003e\n\u003cp\u003eFinally, we proceed with the aortic valve replacement with a conventional mechanical or biological prostheses, as previously described by our group.[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e] XC and CPB times for the combined approach is reasonable (below 90 and 120 minutes respectively for primary MR and below 60 and 90 minutes respectively for secondary MR, after the initial learning curve of the technique). Short term follow-up (mean 5,66 months, range: 0,93\u0026thinsp;\u0026minus;\u0026thinsp;9,9) of our 13 patients operated with the described technique have been excellent with MR\u0026thinsp;\u0026le;\u0026thinsp;1+ (mild).\u003c/p\u003e"},{"header":"Discussion And Conclusion","content":"\u003cp\u003eTotally endoscopic approaches will increasingly become more popular in the years to come. A successful surgical technique of TEAVR and concomitant totally endoscopic mitral valve repair via a trans-aortic approach is presented. When stand-alone endoscopic mitral repair is performed, this is usually done through a more lateral thoracotomy incision through the 4th ICS [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. In order to perform a combined aortic valve replacement and a mitral repair through a standard left atriotomy incision, we can place our working incision through the 3rd ICS in the middle clavicular line, which is a compromise for both the endoscopic aortic valve replacement and the mitral repair through a left atriotomy. Such an approach will make the placement of the aortic annular sutures more difficult, due to the fact that the working incision is not aligned with the aortic annulus, and will prolong the XC time in excess of 120\u0026nbsp;min and the CPB time in excess of 180\u0026nbsp;min. The aortotomy mitral repair approach presented here, significantly shortens the XC and CPB time to 90\u0026nbsp;min and 120\u0026nbsp;min respectively for primary MR and to 60\u0026nbsp;min and 90\u0026nbsp;min respectively for secondary MR, thus making it possible to perform double valve (aortic and mitral) totally endoscopic surgery within reasonable XC and CPB time which are comparable to median sternotomy approaches.\u003c/p\u003e\n\u003cp\u003eContraindications of the presented technique are:\u003c/p\u003e\n\u003cp\u003ea) marked mitral annular dilation - better managed with an annuloplasty procedure through a left atriotomy [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e] and\u003c/p\u003e\n\u003cp\u003eb) P1 or P3 or commissural flail/prolapse - better managed with the loop technique through a left atriotomy [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e] (through a median sternotomy incision if combined with aortic valve disease).\u003c/p\u003e\n\u003cp\u003eThe presented method substantially decreases intensive care times and hospital length of stay, and allows patients to return to work earlier. It should be mentioned that the need for simultaneous aortic and mitral valve surgery is not uncommon, since anterior leaflet prolapse can be found in patients with bicuspid aortic valve [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTEAVR: totally endoscopic aortic valve replacement\u003c/p\u003e\n\u003cp\u003eSAVR: surgical aortic valve replacement\u003c/p\u003e\n\u003cp\u003eXC: cross clamp\u003c/p\u003e\n\u003cp\u003eCPB: cardiopulmonary bypass\u003c/p\u003e\n\u003cp\u003eMR: mitral regurgitation\u003c/p\u003e\n\u003cp\u003eTEE: transesophageal echocardiography\u003c/p\u003e\n\u003cp\u003eICS: intercostal space\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo source of funding was used in the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAP-concept/design, writing of manuscript, NT-data collection, HB-critical revision of article, KDB-critical revision of article. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients involved provided written consent to use clinical information for scientific publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAP is a consultant for teaching and training for Abbott, Medtronic, LSI SOLUTIONS.\u003c/p\u003e\n\u003cp\u003eNT, HB, KDB have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to thank Mr. Isaak Keremidis, perfusionist, for his assistance with data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublisher\u0026rsquo;s Note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRights and permissions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOpen Access\u003c/strong\u003e\u0026nbsp;This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit\u0026nbsp;\u003ca href=\"http://creativecommons.org/licenses/by/4.0/\"\u003ehttp://creativecommons.org/licenses/by/4.0/\u003c/a\u003e. The Creative Commons Public Domain Dedication waiver (\u003ca href=\"http://creativecommons.org/publicdomain/zero/1.0/\"\u003ehttp://creativecommons.org/publicdomain/zero/1.0/\u003c/a\u003e) applies to the data made available in this article, unless otherwise stated in a credit line to the data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePitsis, A., H. Boudoulas, and K.D. Boudoulas, \u003cem\u003eOperative steps of totally endoscopic aortic valve replacement.\u003c/em\u003e Interact Cardiovasc Thorac Surg, 2020. \u003cstrong\u003e31\u003c/strong\u003e(3): p. 424.\u003c/li\u003e\n\u003cli\u003ePitsis, A., et al., \u003cem\u003ePreoperative determination of artificial chordae tendineae length by transoesophageal echocardiography in totally endoscopic mitral valve repair.\u003c/em\u003e Interact Cardiovasc Thorac Surg, 2020. \u003cstrong\u003e31\u003c/strong\u003e(1): p. 20-27.\u003c/li\u003e\n\u003cli\u003eMaisano, F., et al., \u003cem\u003eThe edge-to-edge technique: a simplified method to correct mitral insufficiency.\u003c/em\u003e Eur J Cardiothorac Surg, 1998. \u003cstrong\u003e13\u003c/strong\u003e(3): p. 240-5; discussion 245-6.\u003c/li\u003e\n\u003cli\u003ePitsis, A., et al., \u003cem\u003eMitral valve repair: moving towards a personalized ring.\u003c/em\u003e J Cardiothorac Surg, 2019. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 108.\u003c/li\u003e\n\u003cli\u003eBoudoulas, K.D., et al., \u003cem\u003eFloppy mitral valve/mitral valve prolapse: A complex entity with multiple genotypes and phenotypes.\u003c/em\u003e Prog Cardiovasc Dis, 2020. \u003cstrong\u003e63\u003c/strong\u003e(3): p. 308-326.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"minimally invasive cardiac surgery, totally endoscopic aortic valve replacement, totally endoscopic mitral valve repair, edge-to-edge repair, trans-aortic mitral valve repair","lastPublishedDoi":"10.21203/rs.3.rs-102684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-102684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eMinimally invasive aortic valve procedures through a hemi-sternotomy or a right anterior mini-thoracotomy have gained popularity\u003cstrong\u003e \u003c/strong\u003eover the last several years. Totally endoscopic aortic valve replacement (TEAVR) is an innovative and a less invasive (incision-wise) surgical aortic valve replacement (SAVR) technique. The operative steps of TEAVR have been reported previously from our group. Mitral regurgitation (MR) frequently accompanies aortic valve disease, and sometimes requires repair. Can totally endoscopic surgery be applied in such cases?\u003c/p\u003e\u003cp\u003eCase presentation\u003c/p\u003e\u003cp\u003eWe present the surgical technique of a totally endoscopic approach to aortic valve replacement and concomitant mitral valve repair for primary or secondary MR. We used the aortotomy incision and avoided an atriotomy that would result in a prohibited increase in cross-clamp (XC) and cardiopulmonary bypass (CPB) times and an elevation in mortality and morbidity rates. Neochords (artificial chordae tendineae) were used for the repair of primary MR and the edge-to-edge approach was used for the repair of secondary MR.\u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003eTotally endoscopic aortic valve replacement and concomitant mitral valve repair can be performed transaortically with reasonable XC and CPB times, and excellent short-term results.\u003c/p\u003e","manuscriptTitle":"Totally Endoscopic Aortic Valve Replacement with Concomitant Trans-Aortic Mitral Valve Repair for Mitral Regurgitation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-11-10 15:16:03","doi":"10.21203/rs.3.rs-102684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-08-14T15:20:34+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-04-07T00:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-21T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-12-21T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept\nForm responses:\n---\n\nComments to Author:\n---\nIt is a very interesting article with a new concept and deserves greater exposure for excellent work. The authors have done well by explaining the need to adapt for double valve replacement by choosing the 3rd intercostal space.\nIt would also be helpful if the special instruments required are highlighted in the text.\nThe language is lucid and explanatory although the videos need a bit of editing to avoid viewers having to re run the videos.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-03T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-30T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-29T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-02T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-01T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-01T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-10-30T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66727e3d-cbdf-430d-8394-436af78a1aac","owner":[],"postedDate":"November 10th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1029341,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2021-10-30T11:55:50+00:00","versionOfRecord":{"articleIdentity":"rs-102684","link":"https://doi.org/10.1186/s13019-021-01694-6","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2021-10-30 11:55:50","publishedOnDateReadable":"October 30th, 2021"},"versionCreatedAt":"2020-11-10 15:16:03","video":"","vorDoi":"10.1186/s13019-021-01694-6","vorDoiUrl":"https://doi.org/10.1186/s13019-021-01694-6","workflowStages":[]},"version":"v1","identity":"rs-102684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-102684","identity":"rs-102684","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}