Totally Endoscopic Aortic Valve Replacement With Triangulated Suturing: How to Do It

In the evolving landscape of endoscopic aortic valve replacement (AVR), the alignment of instruments is crucial for overcoming difficulties related to the narrow aortic space. Here, we describe a technique of lateral suturing based on the principle of instrument triangulation, which allows perpendicular stiches to the aortic annulus like an open aortic valve procedure. This technique facilitates endoscopic AVR, performed through a 3 cm long right anterolateral mini-thoracotomy without rib retraction using a 3-dimensional endoscope and femoro-femoral cardiopulmonary bypass. Our approach uses a more lateral positioning of the vent and the transthoracic clamp as well as the addition of a single lateral port, which allows optimal angulation of the instruments to the aortic annulus and the ascending aorta. This technique facilitates endoscopic suturing without the use of automated devices through a transverse aortotomy. Annular sutures are placed in a perpendicular way in the aortic annulus by avoiding challenging "hook" stitches. In this case, we use an additional 10 mm port in the fourth right intercostal space through a small periareolar incision. With this technique, it is possible to implant any type of aortic prosthesis, either biological or mechanical.