Totally endoscopic pulmonary valve replacement.

A 68-year-old man with a history of valve-sparing aortic root replacement and endoscopic aortic valve replacement was admitted to our hospital with dyspnea. Transthoracic echocardiography revealed severe pulmonary valve regurgitation. The patient had undergone cardiac surgery twice, through median sternotomy and right thoracotomy; therefore, we planned endoscopic pulmonary valve replacement via the left thoracic approach. The patient was placed in a modified right lateral decubitus position and underwent mild hypothermic cardiopulmonary bypass. An on-pump beating-heart technique was used during surgery. The 3D endoscopic system and trocars for surgical instruments were inserted through the left 3rd and 4th intercostal spaces. After incision of the pulmonary artery, the pulmonary cusps were resected. A 27-mm St Jude Medical Epic heart valve was implanted in the intra-annular position. Subsequently, the left atrial appendage was resected. The patient was discharged without complications. To our knowledge, this is the first case of totally endoscopic pulmonary valve replacement.