Performing a totally endoscopic aortic valve replacement – that is, operating without opening the patient’s chest, using a fiber-optic bundle of a few millimeters in diameter – is precisely what Italian surgeon Marco Vola and his team at the Saint-Etienne University Hospital (in France) have managed to achieve, the results of which are described in a recent article in the American publication The Journal of Thoracic and Cardiovascular Surgery. In an interview with the Aspen Italia website team, Vola explains that this represents an important step, because these pioneering valve replacements show that cardiac surgery still has the potential to evolve into forms of therapy that are at once radical yet minimally invasive.
Your team has managed to replace an aortic valve by endoscopic means. How did this major breakthrough come about? We have developed a new technique called TEAVR, that is, “Total Endoscopic Aortic Valve Replacement”, which involves the removal of a diseased valve and the insertion of an aortic valve bioprosthesis, thanks to a surgical procedure performed not under direct visual control – which involves making significant thoracic incisions – but guided solely with the aid of a bundle of optical fibers of 5mm in diameter. The operation is made possible by the use of sutureless bioprostheses that can be compressed before being re-expanded again inside the patient’s chest. This allows a drastic reduction in the size of the opening required to access the inside of the chest, down to skin incisions of a few millimeters. The potential benefits for patients of surgery conducted entirely through an endoscopic camera are considerable, as post-operative pain and bleeding are reduced, as is the psychological impact, and there are also less invasive effects from an aesthetic point of view.
So will this give elderly patients a new lease of life? A condition which frequently occurs with aging is the narrowing of the aortic valve and calcification due to valve tissue degeneration. In Europe, 3.4% of the population over 75 years of age currently suffers from severe stenosis of the aortic valve, and each year a total of more than 80,000 bioprosthetic valve replacements are performed, that is, more than 170 surgical interventions per million inhabitants. The frequency of this therapeutic course of action is likely to increase due to population aging. Indeed, it is estimated that the percentage of over-75s in Europe will exceed 10% of the population by 2025.
What prospects does this innovative procedure offer? This type of minimally-invasive surgery, like many other procedures, a good level of reproducibility needs to be reached. So far, we have focused on a limited target group of patients whose anatomical attributes make a “fluid” procedure possible for this type of surgical access. We achieved this outcome after a year of simulations, going on to subsequently perform five replacements in the second half of 2013. Now we need to treat a new set of cases before estimating the pool of patients who could potentially benefit. In the meantime, the aim is to support the parallel development of the surgical technologies used to carry out these operations, so as to expand the number of patients who can undergo this procedure to eventually make it available to everyone. Ultimately, it is technological innovation that will determine its reproducibility and its extension to a wider range of eligible patients.
How do you go about developing a technology like that used in TEAVR? Who is in a position to finance it? The technical development of a surgical tool unquestionably carries not inconsiderable costs, and public funding is not always sufficient at this stage. In France, there is a certain degree of complementarity between the public and private sectors, often manifested in forms of co-financing by public bodies, which are more willing to fund the development of a device if there is a corresponding private undertaking in place, perhaps even from the company that is exploring the technology in question. This also makes it easier for such firms to access capital markets, thereby facilitating their visibility and funding.
I believe it’s a system that is also replicable in Italy, where cardiovascular surgery has a fertile seedbed of ideas to be harnessed. In fact, it’s important to remember that innovation in the field can also have considerable positive economic effects. One need only look at the benefits – including in terms of employment – generated in a more advanced market, such the United States, by firms engaged in research and innovation in the area of healthcare. And I am convinced that investing in what we might call “the surgery of tomorrow” – TEAVR being one such example – is a step in that direction.
Marco Vola heads the activities and development program for minimally-invasive heart surgery of the Department of Cardiovascular Surgery at the Saint-Etienne University Hospital. After graduating in Turin, he specialized in France, where he has worked for 10 years. He was awarded the “Lauréat des Victoires de la Médecine” for Cardiology in Paris in 2010.
