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

Abstract

There is an ever-growing trend towards less-invasive procedures in all fields of medicine. We designed an animal study to prove the concept that trans-apical aortic valve replacement from an incision within the umbilicus through a single channel for instruments is feasible, which would be a major leap towards no-scar cardiac surgery. In three adult pigs, after creating a single 3-cm incision at a place where the human umbilicus would be, we introduced a 30F sheath through a tunnel created by an endoscopic vein-harvesting device up to the cardiac apex, through it and up to the left ventricle simulating the approach for trans-apical aortic valve replacement. We used a standard Amplatz nitinol occluder to seal the defect in ventricle wall later. The animals were followed up for 1h. Blood loss was minimal, and no tamponade occurred in any of the animals. In addition, we performed a test with water column static pressure to evaluate the impact of preclotting on the sealing properties of the occluders: 1 min flow-through was 2860+/-176 ml for the standard occluders and 348+/-56 ml for preclotted occluders (p<0.001).

EACTS Presidential Address The contraindications of today are the indications of tomorrow

“…Of course, this can also be applied to cardiothoracic surgery, and this despite the fact that there is no natural orifice leading to the heart. But the umbilicus is not too far away, and a small incision can be made inside as reported by Kalejs et al [40]. For this purpose, a channel was developed from the umbilicus to the pericardial sac behind the processus xyphoides using a saphenous-vein-harvesting device.…”

“…(C) NOTES for cardiac valve implantation: a trans-umbilical route was developed with an endoscopic saphenous-vein-harvesting system for TAVI. Cardiac access closure was realized with an occluder [40].…”

Transcatheter aortic valve implantation (TAVI): state of the art techniques and future perspectives

“…Regarding the transapical minimal invasiveness and the latest alternative access point, our group has already proposed, in an animal model, the use of "natural orifices", such as the umbilicus, for transapical or transventricular stent-valve implantations, where the delivery system is introduced into the human body through a natural skin access point [59].…”

Apical closure device for full-percutaneous transapical valve implantation: stress-test in an animal model†

“…After previous pilot studies with modified ventricular septal defect occluders [5][6][7][8] and after our preliminary report on efficacy and safety of the new apical occluder (the prototype) in an animal setting [9], we have tested the sealing properties of the device's final design under stress.…”