The principles of minimally invasive atrioventricular valve repair surgery utilizing endoaortic balloon occlusion technology: how to start and sustain a safe and effective program

Johan Van der Merwe, Filip Casselman, Frank Van Praet


The ongoing evolution in therapeutic transcatheter (TC) and minimally invasive surgical technology for atrioventricular valve (AVV) disease is paralleled by an aging- and higher surgical risk patient population, increasing public expectations, quality control and clinical governance. International treatment guidelines and changes in referral patterns progressively favour less invasive procedures, which require that both current- and future cardiac surgical practices become proficient in minimally invasive atrioventricular valve surgical (MIAS) and TC procedures. The transition from classic sternotomy access to MIAS approaches that utilizes videoscopic- or robotic vision, modified long-shafted instruments, transoesophageal echocardiographic- (TEE) or fluoroscopic guidewire directed peripheral cardiopulmonary bypass (CPB) and endo-aortic balloon occlusion device placement [Port Access™ Surgery (PAS)] are associated with learning curves that are challenging to master in an era of decreasing surgical volume, training opportunities and healthcare cost constraints. Excellent perioperative- and long term outcomes with the routine application of MIAS utilizing PAS technology for isolated primary- and redo-AVV procedures are reported and it is suggested that the introduction of PAS in new centres should follow a systematic approach that include careful infrastructure planning, MIAS and PAS skills development and careful initial patient selection criteria under expert guidance. This manuscript provides an overview of the historic evolution of PAS, contemporary PAS technology, PAS infrastructure planning and the operative principles of PAS with the intention of assisting upcoming centres to establish and maintain safe- and effective PAS programs.