Aortoscopy
Assessment of post-repair cusp configuration is sometimes difficult under unpressurized conditions. Indeed, Sievers clearly demonstrated that the irregular leaflet appearance in the absence of diastolic pressure could be restored with normal diastolic pressure (Fig. 11)52. This may be one reason why AVP is limited to experts. In 1997, Itoh et al. applied endoscopy to evaluate cusp geometry before and after AVP under physiological (pressurized) conditions, and reported the usefulness of this strategy53. The Essen group revived this procedure in 2014 and confirmed the consistency with transesophageal echocardiographic findings54. Okita and colleagues observed the valve from the left ventricular side using a flexible videoscope, but they could not clarify the etiology of the failure55.
We have used aortoscopy since December 2015 in over 90 cases undergoing both VSRR and isolated AVP56. Although it prolongs the procedure time up to 20 – 30 minutes, AVP has become more sophisticated and reproducible with less residual AR than before the introduction of aortoscopy. The only drawback is the use of a non-negligible amount of crystalloid cardioplegic solution that should be minimized to prevent hemodilution.