Objectives: Fully-endoscopic combined tricuspid (TV) and mitral valve (MV) surgery has been established over the years and is traditionally performed via femoro-femoral cannulation including snaring of superior and inferior caval veins for complete cardiopulmonary bypass (CPB). We herein report experience with fully-endoscopic combined valve surgery including TV repair on partial bypass and without bicaval snaring.
Methods: From 2023 to 2025, a total of 35 consecutive patients underwent fully-endoscopic valve surgery using the above-mentioned technique. Surgical technique included endoscopic access with percutaneous femoro-femoral cannulation using bicaval drainage by temporary stenting of caval veins. Adaptation of vacuum-assisted venous drainage (VAVD), central venous pressure (CVP) and a slightly feet-downward tilted patient position were identified as significantly relevant for technical feasibility. Beating-heart TV surgery followed arrested heart left-sided valve procedures. Clinical and hemodynamic outcomes were adjudicated in accordance with Mitral Valve Academic Research Consortium (MVARC) definitions to 30 days.
Results: Patients (60.0 % male, age 66.1± 12.4 years; EuroSCORE II 2.2± 1.3%) received TV repair (34/35; 97.1%) and one case of endocarditic vegetation resection combined with MV repair or replacement in 77.1% (27/35) and 20.0% (7/35,) of cases. Concomitant atrial fibrillation ablation and left atrial appendage closure were performed in 31.4% (11/35) and 40.0% (14/35) of cases. Cardiopulmonary bypass and cross-clamp times were 176.40± 39.0 and 90.0± 30.0 min. VAVD and CVP on complete bypass and during beating heart TV procedures were -56.7± 5.3 and 0.4± 5.3 mmHg and -43.5± 7.0 and -0.8± 2.3 mmHg, respectively. No 30-day mortality, stroke, myocardial infarction or acute kidney injury were observed. Echocardiography demonstrated excellent results after TV and MV repair / replacement with TV and MV regurgitation ≤ I° in all cases.
Conclusion: Fully-endoscopic TV surgery during combined procedures on partial CPB without bicaval snaring is feasible and safe using a self-expanding venous cannula for temporary caval stenting. This simplified procedure allows for reduced aortic cross-clamp and myocardial ischemic times while preserving excellent results regarding valve repair and has become our default technique.
