COMBINED ENDOSCOPIC VALVE SURGERY AND CORONARY ARTERY BYPASS VIA MINI-THORACOTOMY

Background: Consistent evidence favors of endoscopic valve surgery (eVS) exists. Yet, the adoption of minimally invasive coronary surgery (MICS) remains low, particularly for combined procedures. We aim to describe our experience with combined eVS and MICS. Methods: We reviewed patients who underwent eVS+MICS at Santa Maria Hospital, Bari, from 2021-2024. The primary outcome was follow-up mortality. Patients received MICS and either endoscopic mitral repair (eMVr) or aortic valve replacement (eAVR). After double- lumen endotracheal intubation, right internal jugular vein cannulation, right groin incision for echo-guided cannulation, cardiopulmonary bypass establishment, Chitwood clamp insertion at the second interspace (IS-2), eMVr was performed via right-MT above the nipple at IS-4 while eAVR via anterior MT at IS-3. MICS consisted of a left internal thoracic artery (LITA) to left anterior descending off-pump graft via an additional left-MT at IS-5 in eMVr cases, and a saphenous vein (SVG) to posterior descending artery (PDA) graft via the same right-MT, in eAVR cases. Results: Thirteen patients underwent eVS+MICS: age was 67±4 years, 8 were male, and EuroSCORE II was 2.6±1.1. Nine patients had eMVr: 6 posterior leaflet resections, and 4 neochordal repairs. All eMVr included ring annuloplasty; four had monopolar ablation and left atrial appendage closure. Four patients had eAVR with bioprosthesis and SVG-to-PDA. Mechanical ventilation averaged 4±2 hours, with ICU discharge after 2±1 days. All patients were discharged healthy, with no deaths at 2-year follow-up. Conclusion: Combined eVS+MICS is safe, with satisfactory outcomes. Minimally invasive techniques should be adopted in specialized centers, even in complex cases.