Totally endoscopic non-robotic excision of aortic valve fibroelastoma: a case report

Papillary fibroelastomas (PFE) are rare primary tumours of cardiac origin accounting for approximately 10% of all primary cardiac neoplasms [3]. They may occur anywhere on the endocardium, although are more common in the left heart and display a predilection for valvular structures. The aortic valve is the most commonly affected, with a number of such tumours arising from the non-coronary leaflet. Whilst the majority are incidental findings on echocardiography, symptoms most commonly occur subsequent to embolization, and may give rise to a wide variety of presenting features including neurological events (transient ischaemic attack, stroke, amaurosis fugax, spinal cord infarction), acute coronary syndrome, and distal thromboembolism [3]. PFES removal may require, when the implantation on the valvular tissue is large, extensive aortic valve reconstruction or aortic valve replacement.

In our patient PFE base was implanted exclusively on the free edge of the right coronary cusp with a fine pedicle and a low probability of needing a complex aortic valve reconstruction after resection. Some anatomical criteria, like non-obesity BMI, and the aorto iliac suitability for a retrograde arterial perfusion, encouraged us to consider an endoscopic minimal access targeting a superior post-operative early life quality rather than a ministernotomy.

Although median sternotomy is the usual approach, removal of the aortic valve PFEs by ministernotomy or robotic approach have been reported [3, 4].

Robotic adoption in totally endoscopic aortic valve setting has been shown to be very promising when performed in specialized centres [4]. In theory, robotic setting, considered the high grade of liberty of the tips of the instruments, should provide the possibility of more technically demanding aortic valve free margin reconstruction, or larger indications in more challenging anatomical settings (e.g., obesity). But reports are too rare to any statistical conclusion, and the cost of the robotic equipment may limit the adoption in small centres.

Totally endoscopic cardiac surgery has shown to improve early life quality when compared with open full sternotomy and minithoracotomy approaches for myocardial revascularization and atrial septal defect repair and it also showed successful aortic valve replacement in a cohort of selected low risk patients with very encouraging results in terms of post-operative paravalvular leakages, conduction blocks and early life quality [2].

Based on our previous experience of TEAVR [2] endoscopic magnification, appropriate aortotomy, aortic margins traction, could provide in this case an excellent exposure to visualize the appropriate cutting of the base of the fibroelastoma. The patient presented an intra pericardial length of the ascending aorta superior to 6 cm and respected all the other selection criteria that we previously applied in TEAVR [5].

The encouraging intra and post-operative outcomes and fast recovery showed the potential benefits of a non-robotic totally endoscopic removal of PFE. We hope that this totally endoscopic surgical option will be reproducible in future similar cases, beginning from centres that already perform right minithoracotomy approaches for aortic valve surgery.

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