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.