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Aortic root endoscopy for aortic valve–sparing operations

      To the Editor:
      Author have nothing to disclose with regard to commercial support.
      We read with great interest the article by Tsagakis and colleagues
      • Tsagakis K.
      • Benedik J.
      • El Khoury G.
      • Jakob H.
      Aortic valve repair: intraoperative evaluation of valve geometry by angioscopy.
      on the intraoperative evaluation of repaired aortic valve geometry by angioscopy. We have been using aortic root endoscopy in valve-sparing aortic root replacement operations at our institutions since 1995.
      • Itoh T.
      • Ohtsubo S.
      • Furukawa K.
      • Norita H.
      Aortic root endoscopy in valve-spring operations.
      • Ohtsubo S.
      • Itoh T.
      • Natsuaki M.
      • Furukawa K.
      • Yoshikai M.
      • Suda H.
      • et al.
      Successful valve-sparing in aortic root reconstruction under endoscopic guidance.
      We would like to comment on the efficacy of intraoperative endoscopy to evaluate repaired aortic valves.
      Intraoperative macroscopic evaluation of a repaired aortic valve is not always accurate because the aortic cusps are released from the perfusion pressure and the root loses its tension once the root is opened. The natural configuration of the root is thus altered, and recognizing any malcoaptation or overstretching becomes difficult.
      • Itoh T.
      • Ohtsubo S.
      • Furukawa K.
      • Norita H.
      Aortic root endoscopy in valve-spring operations.
      Experience is required to predict the result of repair and to avoid secondary aortic clamping for additional valve repair or replacement.
      • Tsagakis K.
      • Benedik J.
      • El Khoury G.
      • Jakob H.
      Aortic valve repair: intraoperative evaluation of valve geometry by angioscopy.
      Prolapse of the repaired aortic valve could be among the factors that cause suboptimal long-term results.
      • Pethig K.
      • Milz A.
      • Hagl C.
      • Harringer W.
      • Haverich A.
      Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early valve failure.
      However, detection of prolapse during cardiac arrest is difficult. Recently, effective height has been used for detection of prolapse of repaired aortic valves.
      • Schäfers H.J.
      • Bierbach B.
      • Aicher D.
      A new approach to the assessment of aortic cusp geometry.
      The effective height is an excellent parameter for detection of minor valve prolapse. However, the result would be influenced by the retraction tension on the commissures and the amount of force on the free margin of the valve by the caliper bar. Therefore, an error could occur because of these factors. Thus, we evaluate the aortic valve before and after repair using intraoperative endoscopy combined with macroscopic findings and the measurement of effective height.
      After crossclamp of the ascending aorta, crystalloid cardioplegic solution is infused into the root, and this allows visualization of the pressure-loaded valve in the closed position. A videoscope (Olympus LTF type VH; Olympus, Tokyo, Japan) is inserted into the aortic root and the aortic valve is investigated. The final indication for valve sparing is determined based on the endoscopic findings. Then, aortic root remodeling is performed. First, the effective height of the repaired aortic valve after aortic root replacement is measured. Next, a videoscope is placed within the lumen in the clamped prosthetic graft with perfusion of normal saline under physiologic pressure (50-80 mm Hg). The measurement of effective height along with the endoscopy findings could result in the need for an additional procedure before weaning from cardiopulmonary bypass if there is prolapse of the cusps. If necessary, additional central plications are performed to the prolapsed cusps and endoscopy is repeated. Finally, the optimal configuration of the valve is confirmed with endoscopy (Figure 1). After confirmation, bleeding is evaluated by perfusion of blood into the graft, and some additional hemostatic sutures are placed if necessary. Then, both coronary arteries are reconstructed and the distal graft anastomosis is completed.
      Figure thumbnail gr1
      Figure 1Intraoperative aortic root endoscopic findings. Left, Left and noncoronary cusps were prolapsed after remodeling. Right, Optimal configuration of central plicated left and noncoronary cusps was confirmed. L, Left coronary cusp; N, noncoronary cusp; R, right coronary cusp.
      Although determination of the actual degree of aortic regurgitation might be difficult and the image is only 2-dimensional, the endoscopic method is simple and reproducible. This method allows the opportunity to correct a minor prolapse and leak before aortic declamping.
      In conclusion, with the combination of effective height measurement and the aortic root endoscopy, more detailed information on the repaired valve can be obtained. As a consequence, improved results of the aortic valve-sparing operation may be obtained.

      References

        • Tsagakis K.
        • Benedik J.
        • El Khoury G.
        • Jakob H.
        Aortic valve repair: intraoperative evaluation of valve geometry by angioscopy.
        J Thorac Cardiovasc Surg. 2015; 149: 1666-1668
        • Itoh T.
        • Ohtsubo S.
        • Furukawa K.
        • Norita H.
        Aortic root endoscopy in valve-spring operations.
        J Thorac Cardiovasc Surg. 1997; 114: 141-142
        • Ohtsubo S.
        • Itoh T.
        • Natsuaki M.
        • Furukawa K.
        • Yoshikai M.
        • Suda H.
        • et al.
        Successful valve-sparing in aortic root reconstruction under endoscopic guidance.
        Eur J Cardiothorac Surg. 2000; 17: 420-425
        • Pethig K.
        • Milz A.
        • Hagl C.
        • Harringer W.
        • Haverich A.
        Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early valve failure.
        Ann Thorac Surg. 2002; 73: 29-33
        • Schäfers H.J.
        • Bierbach B.
        • Aicher D.
        A new approach to the assessment of aortic cusp geometry.
        J Thorac Cardiovasc Surg. 2006; 132: 436-438

      Linked Article

      • Aortic valve repair: Intraoperative evaluation of valve geometry by angioscopy
        The Journal of Thoracic and Cardiovascular SurgeryVol. 149Issue 6
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          Aortic valve (AV) repair still represents a surgical challenge. To obtain optimal AV function, adequate interaction of all anatomic components is crucial. This includes the integrity and geometry of the AV leaflets as well as the dimension of the aortic annulus, sinotubular junction, and ventriculoaortic junction. The result of the repair has to be done directly during cardioplegic arrest with a depressurized aortic root and left ventricle. Experience is required to predict the result of the repair and to avoid secondary aortic clamping for valve re-repair or replacement.
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      • Aortic root endoscopy
        The Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 2
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          We thank and give credit to Furukawa and colleagues1 and Itoh and colleagues2 for the introduction of aortic root and valve endoscopy during aortic valve (AV)-sparing surgery in 1995. The fact that the accuracy of on-clamp AV evaluation in the diastolic position under pressure was demonstrated by Itoh and colleagues, and confirmed by us, thus encouraging our policy to control the AV endoscopically after repair and to proceed to additional valve corrections immediately without echocardiographic examination.
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