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Minimally Invasive Cardiac Surgery Using a 3D High-Definition Endoscopic System

Ruttkay, Tamas MD; Götte, Julia MD; Walle, Ulrike MD; Doll, Nicolas MD, PhD

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery: November/December 2015 - Volume 10 - Issue 6 - p 431–434
doi: 10.1097/IMI.0000000000000216
Case Reports

We describe a minimally invasive heart surgery application of the EinsteinVision 2.0 3D high-definition endoscopic system (Aesculap AG, Tuttlingen, Germany) in an 81-year-old man with severe tricuspid valve insufficiency. Fourteen years ago, he underwent a Ross procedure followed by a DDD pacemaker implantation 4 years later for tachy-brady-syndrome. His biventricular function was normal. We recommended minimally invasive tricuspid valve repair. The application of the aformentioned endoscopic system was simple, and the impressive 3D depth view offered an easy and precise manipulation through a minimal thoracotomy incision, avoiding the need for a rib spreading retractor.

From the Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.

Accepted for publication January 14, 2015.

Disclosures: Nicolas Doll, MD, PhD, is a consultant for AtriCure, Inc., West Chester, OH USA. Tamas Ruttkay, MD, Julia Götte, MD, and Ulrike Walle, MD, declare no conflicts of interest.

Address correspondence and reprint requests to Tamas Ruttkay, MD, Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Herdweg 2, 70174 Stuttgart, Germany. E-mail:

The first video-assisted mitral valve repair was performed in 1996.1 In the same year, the application of special instruments and cannulation techniques as well as 3-dimensional (3D) camera guidance were used the first time in minimally invasive mitral valve surgery.2 In the following years, robotic systems (da Vinci) with a 3D intracardiac endoscopic optic allowed for safe manipulation also in the closed chest.3 Since then, a number of series of mitral surgery were performed worldwide applying this technique.4 In the past few years, the advantages of a 3D surgical endoscope without robotic systems5,6 have been used predominantly in laparoscopic surgery.7–9 After improvements of limitations of the first generation, the EinsteinVision 2.0 system (Aesculap AG, Tuttlingen, Germany) has been developed. The most current 3D endoscopic system version was applied in minimally invasive cardiac surgery at our institution. The case performed was a beating heart tricuspid valve repair in an 81-year-old man. Details of this case will be described in the following report.

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The 3D High-Definition Endoscopic System

The EinsteinVision 2.0 endoscopic system applies most up-to-date high-definition (HD) standard of 3D technology. The camera head is easy to maneuver owing to its extremely reduced volume and weight. The optical system (EV2-000053) represents the combination of a 3D camera head, a 10-mm diameter zero-degree dual-channel endoscope and a hybrid cable (combined camera cable and light guide) (Fig. 1A). A sterile single-use sheath (EV2-000055), which hermetically seals the complete endoscope as well as the camera and its hybrid cable, is used as a sterile barrier between the patient and the camera system. The integrated glass cover on the distal end of the sterile sheath offers a clear view of the surgical site. A “tip heater” is integrated into the distal end of the endoscope to balance out the difference in temperatures and prevent fogging on the tip of the optic. Aesculap uses native-resolution full HD sensors in 3D endoscopy, which provide a low-noise, high-contrast, razor-sharp image in 16:9 format. It is an optical system in which the entire surgical site is rendered in an impressive image definition when wearing 3D polarization glasses (EV-000023). Everything is in focus owing to high depth perception, and digital zooming is possible.10



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An 81-year-old man presented with symptoms of right-sided heart failure and permanent atrial fibrillation. Echocardiography demonstrated tricuspid valve insufficiency with normal biventricular function. Function of the other valves was normal. On cardiac catheterization, a nonsignificant left anterior descending coronary artery stenosis had been identified. His surgical history included a Ross operation (2000) and a DDD pacemaker implantation (2004) for tachy-brady syndrome. We recommended minimally invasive surgical repair of the tricuspid valve.

The procedure was carried out using a 4-cm right anterolateral thoracotomy incision in the fourth intercostal space. Cardiopulmonary bypass was established after cannulation of the right femoral vessels using a 2-cm inguinal incision. After insufflation of the left pleural cavity with CO2, the EinsteinVision 2.0 3D HD endoscopic system was introduced using a standard port through the third intercostal space and held in position through a standard pneumatic device (Fig. 2). All steps of the surgery were carried out completely video-assisted and without the use of a rib retractor. The lung showed no adhesions, but the pericardium was attached to the wall of the right atrium secondary to previous cardiac surgery. The right atrium was opened 4 cm anterior and parallel to the right phrenic nerve (Fig. 3A) and retracted using a standard atrial retractor to visualize the insufficient tricuspid valve (Fig. 3B). The annulus was significantly dilated. We decided to implant a Medtronic Contour 3D (34 mm) annuloplasty ring. The implantation was performed with interrupted stiches using plegets only in the area of the septal leaflet (Figs. 3C–E). When performing the sealing test after the annuloplasty was completed, the tricuspid valve (Fig. 3F) was entirely competent. The right atrium was closed with a running suture. After weaning from cardiopulmonary bypass, the transoesophageal echocardiography showed an ideal result of the repair. There was no evidence of bleeding, the thoracotomy approach and the port sites were closed after positioning a 28-F chest tube through the endoscopic port site (Fig. 1B). The operative time was 170 minutes with a 124-minute cardiopulmonary bypass time.





The patient had a prolonged intensive care unit stay secondary to an acute respiratory distress syndrome. Upon transfer for further pulmonary care to his local hospital, his discharge echocardiogram showed normal biventricular function and an optimal result after tricuspid valve repair without any evidence of regurgitation. Unfortunately, the patient died through respiratory insufficiency on postoperative day 24.

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Our case report offers a detailed description applying the EinsteinVision 2.0 endoscopic system in minimally invasive cardiac surgery.

Owing to the “all-in-one concept” at the head of the endoscope, the introduction into the pleural cavity and the manipulation of the scope were easy. The anti-fog “heater” at the tip of the optic allowed for a clean view of the operative field throughout the entire case.

The correct location of the endoscopic port was essential to gain an optimal view. When positioned in the intercostal space right above the thoracotomy, the zero-degree optic offered a free visualization without any visual distortion of the cardiac structures. The impressive 3D depth view allowed for an easier performance of all surgical steps, particulary improving the approach to the subvalvular apparatus. Perfect visualization of deep structures was possible by using the digital zoom, and hence, further introduction of the camera into the pleural cavity with the risk of any injury to surrounding structures could be avoided.

In our patient, a 4-cm skin incision was suffice to perform the entire surgery without any compromise to technical precision, resulting in a completely competent tricuspid valve upon completion of the case. Beyond that, the use of a rib retractor was not necessary when using the aforementioned 3D videoscope. Postoperative chest wall pain and hematomas from spreading the ribs with retractors commonly used in minimally invasive cardiac surgery have been complicating the recovery for many patients in the past. The direct visualization of the valve through the thoracotomy is limited without using a retractor, wherefore the 3D depth perception through the endoscopic optic is even more important to hold the operative results. Adding 3D vision to the concept of minimally invasive cardiac surgery will help surgeons reduce the surgical trauma, and hence minimize their approach beyond current standards.

The cost difference between 2D and 3D endoscopic systems is an important consideration too. Actually, the 3D system costs 3 times as much as the 2D system at the same company. However, medical benefits and the reduction of other perioperative hospital costs through shorter operative times and smaller skin incisions could compensate the higher costs of the 3D device. After overcoming the learning curve, the EinsteinVision 2.0 endoscopic system has the potential for a completely endoscopic visualization approach in minimally invasive cardiac surgery, allowing to minimize the thoracotomy incision and avoiding the use of a rib retractor without any compromise in surgical precision.

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The use of the Einstein Vision 2.0 endoscopic system in our clinic was carried out with the help of the coworkers of Aesculap AG, Tuttlingen, Germany: Frank Boos, Jennifer Kaestle, Rudi Zepf, Thomas Beck; and Schölly Fiberoptic GmbH, Denzlingen, Germany: Bettina Sabban and Marc Kalmbach. For the technical description of the system, Aesculap AG gave us free the information and photograph (Fig. 1A) from the product brochure (No. C92602 0214/0.75/1).

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10. Aesculap product brochure (No. C92602 0214/0.75/1).

Endoscopic surgery; Tricuspid valve; Tricuspid valve repair; Minimally invasive cardiac surgery

©2015 by the International Society for Minimally Invasive Cardiothoracic Surgery