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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. Meanwhile and after experience with AV endoscopy in more than 100 elective and emergency cases, this technique improved our knowledge about “how to do and choose” valve-sparing repair techniques respecting the anatomic configuration of the AV components to achieve a symmetric and functionally accurate configuration of the valve apparatus.
The complexity of the AV apparatus requires extensive experience to deal with sizing, commissures, remnant aortic wall fixation, and free margin reconstruction. Techniques to standardize parameters, such as an effective height of leaflets and commissures, facilitate the decision making intraoperatively but do not reduce the complexity of the procedure and technical failure. Malas and colleagues
estimated a learning curve of approximately 40 to 60 AV-sparing surgeries to reproduce the safety and efficiency of the technique. Thus, in our opinion, the surgeon's experience remains the most important factor for durable AV and root repair.
Echocardiography is the only instrument to evaluate the AV result after repair. Residual regurgitation, coaptation length, and prolapse are detected accurately. However, echocardiography does not differentiate directly the reason for residual valve pathology according to the surgical steps. Prolapse postoperatively may result from isolated or combined findings, including commissural stretching, leaflet reduction or elongation by reimplantation, free margin under- or overcorrection, and annulus undersizing. Likewise, in case of a functional accurate but asymmetric valve after repair, no definitive statement to improve the surgeon's technique is given.
AV endoscopy enables the visualization and differentiation of such important details. The resulting leaflet position and symmetry can be studied and related to the commissural, supra-annular, or free-margin stitches. However, as Sievers
mentioned, a pressure level of 60 mm Hg minimum is required to push the leaflets to the end-diastolic position and to evaluate coaptation and symmetry (Video 1). Endoscopy does not reduce the importance of intraoperative tools and techniques that are used for the standardization, safety, and durability of AV repair. Endoscopy enables only the control of the result before clamp release and initiates minor or major corrections, if required. It is the only instrument that can demonstrate directly the result of surgical techniques in cardiac and aortic surgery, giving important information to understand the AV pathology and to improve the surgical technique. In our department, endoscopy enabled a more sophisticated methodology to choose the repair technique.
A maintained pressure in the aortic root at a minimum of 60 mm Hg is required to assess the AV by endoscopy. The video demonstrates the movement of the noncoronary leaflet (on the right) to end-diastolic position under increasing pressure after supracoronary ascending aorta replacement in acute aortic dissection. Video available at: http://www.jtcvsonline.org/article/S0022-5223(16)30298-7/addons.
Aortic root endoscopy for aortic valve-sparing operations.
We read with great interest the article by Tsagakis and colleagues1 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 1995.2,3 We would like to comment on the efficacy of intraoperative endoscopy to evaluate repaired aortic valves.