Totally Endoscopic Aortic Valve Replacement in a High-Volume Center: Implementation, Feasibility, and Early Outcomes

All articles of this category (opens in new window) Background: Surgical aortic valve replacement (SAVR) has progressively transitioned from conventional median sternotomy to less invasive strategies. While partial upper sternotomy reduced surgical trauma and improved cosmetic results, the more recent implementation of totally endoscopic techniques has enabled complete sternal-sparing SAVR. This study aimed to evaluate the feasibility, procedural characteristics, and early outcomes of totally 3D endoscopic AVR in a high-volume center. Methods: Between May 2024 and June 2025, 36 patients with symptomatic aortic valve disease underwent isolated totally 3D endoscopic AVR with fully percutaneous femoral cannulation. Procedural variables, early clinical outcomes, and 30-day mortality were prospectively assessed according to VARC-3 definitions. Results: Mean patient age was 65.4 ± 6.7 years; 63.9% were male. The mean STS score was 1.1 ± 0.4% and EuroSCORE II 1.0 ± 0.4%. Conventional stented bioprostheses were implanted in 83.4% (30/36) and sutureless valves in 16.6% (6/36). All procedures were completed without conversion to sternotomy. No major stroke or myocardial infarction occurred. Re-thoracotomy for bleeding was required in three patients (8.3%), all due to bleeding from the thoracic wall. Acute kidney injury occurred in one patient (2.8%) and new pacemaker implantation in two (5.5%). Extubation in the operating room was achieved in 22.2% (8/36), while the remainder were extubated after 4.0 ± 1.9 hours. Postoperatively, 19.4% (7/36) were transferred to a 24-hour postoperative anesthesia care unit (PACU) and 80.6% (29/36) to an intensive care unit (ICU), with a mean ICU stay of 1.5 ± 1.2 days. Thirty-day mortality was 0%. Echocardiography confirmed no paravalvular leakage and a mean gradient of 12.7 ± 4.3 mmHg. Conclusion: Implementation of totally 3D endoscopic SAVR is technically feasible and safe with excellent early clinical and hemodynamic outcomes. This minimally invasive approach was successfully established in a high-volume center, reducing surgical trauma without compromising procedural success, underscoring its potential to accelerate recovery and optimize perioperative resource utilization. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany