{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T12:49:15Z","timestamp":1785761355842,"version":"3.56.0"},"reference-count":25,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Minimally invasive approaches for combined aortic valve and ascending aortic surgery remain challenging. We report a case of utilizing a transaxillary approach (TAX) in combination with the RAM\u00ae system. Methods: A 65-year-old male presented with exertional angina and palpitations. He reported a one-year history of dizziness. Diagnostics revealed severe aortic regurgitation due to a calcified bicuspid aortic valve and an ascending aortic aneurysm measuring 57 \u00d7 54 mm. Left ventricular ejection fraction was reduced to 42%. Coronary artery disease was excluded. Surgery was performed via a right transaxillary mini-thoracotomy (3rd intercostal space) using endoscopic visualization. Cardiopulmonary bypass was established through femoral cannulation. After aortic cross-clamping and cardioplegic arrest, the bicuspid valve was excised and replaced with a bioprosthesis. A supracoronary ascending aortic replacement was performed using a Dacron graft. The RAM\u00ae system was used for annular suturing and proximal anastomosis, with automated fastener fixation. Results: The patient was extubated on postoperative day 1 and transferred to intermediate care on day 2. Postoperative recovery was uneventful, with no neurological deficits, bleeding, or other complications. Discharge occurred on postoperative day 9 in stable condition. Conclusions: This case highlights the feasibility and safety of a minimally invasive transaxillary approach for combined aortic valve and ascending aortic replacement using the RAM\u00ae system. This technique may expand the surgical armamentarium for complex aortic pathology while avoiding sternotomy. Further studies are required to evaluate reproducibility, long-term outcomes, and broader applicability.<\/jats:p>","DOI":"10.3390\/jcm15155996","type":"journal-article","created":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T11:50:21Z","timestamp":1785757821000},"page":"5996","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Redefining Access: Transition from Conventional to Transaxillary Endoscopic Aortic Valve and Ascending Aorta Replacement\u2014A Case Report with Literature Review"],"prefix":"10.3390","volume":"15","author":[{"given":"Tanja","family":"Josic","sequence":"first","affiliation":[{"name":"Department of Cardiac Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mirko","family":"Doss","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"27","DOI":"10.14797\/mdcj-12-1-27","article-title":"Aortic Valve Surgery: Minimally Invasive Options","volume":"12","author":"Ramlawi","year":"2016","journal-title":"Methodist DeBakey Cardiovasc. 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