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J Thorac Cardiovasc Surg 1994;107:632-0634
© 1994 Mosby, Inc.

Letters to the Editor

A simple method for intraoperative visualization of the repaired aortic valve*

Department of Cardiovascular Diseases
King Faisal Specialist Hospital and Research Centre
Riyadh, Saudi Arabia

To the Editor:

Conservative surgery of the aortic valve, although it has a long history extending back to the days before cardiopulmonary bypass, has only recently been the subject of renewed interest. ^{1, 2} Many techniques have been proposed to evaluate the degree of competence achieved. Experience has shown that the direct observation of the repaired valve with an open aorta is not a reliable method to test its competence. Once the aorta is unclamped, the measure of the regurgitant volume obtained through the left vent as originally described by Austen and coworkers ³ for the postmortem heart, is inaccurate and does not provide information on the cause of the regurgitation. If significant, regurgitation necessitates reclamping of the aorta, cooling of the patient, and a new administration of cardioplegic solution. Intraoperative color Doppler echocardiography, although extremely accurate, can only be performed once the patient has been weaned from bypass. In 1963, Ebert, Morrow, and Austen ⁴ and Hudspeth and Cardell ⁵ described two extremely similar methods to visualize the aortic valve before unclamping the aorta. A wide-bore, transparent tube, open at one end and closed at the other, was inserted into the proximal aortic root. A tape maintained it in position while saline solution was infused under pressure through a side arm in the tube. These viewers were cumbersome, were difficult to maintain in position, and had to be custom built. The application of the same principle, but with a modern endoscopic instrument, forms the basis for our report.

Once the aortic repair has been completed, the aorta is closed with two running 4-0 Prolene sutures (Ethicon, Inc., Somerville, N.J.) started at each extremity of the aortotomy. Before they are tied anteriorly, the two arms of the sutures are passed through a tourniquet. By loosening the uppermost part of the suture, only the fiberoptic part of a No. 17 cystoscope with a 30-degree lens (Hopkins Type; Storz AM Mark Tuttlingen GMBH, Emmingen-Liptingen, Germany) is introduced into the ascending aorta (Fig. 1). A 1 L bag of cold crystalloid cardioplegic solution is connected to the ascending aorta suction needle and run under pressure delivered by a pressure bag. This fluid is run to fill the aortic root while the aortotomy tourniquet is loose, and the surgeon applies pressure on the orifices of the right and left coronary arteries to avoid air embolism. Once absence of any air bubbles has been confirmed visually by observation through the viewer, the aortotomy tourniquet is tightened. The left ventricular vent is maintained under suction throughout the procedure. The repaired aortic valve can then be seen directly by the surgeon and photographed or recorded on videotape (Fig. 2). Once the viewing is finished, the viewer is removed and the aortotomy is closed by tightening the two running sutures and tying them to each other. The aorta is unclamped after application of suction to the aortic needle, and rewarming is started. If the repair is seen to be unsatisfactory, the aortotomy is reopened after removal of the viewer and further surgical maneuvers are undertaken.

View larger version (20K): [in this window] [in a new window]   Fig. 1. Viewing instrument.

View larger version (170K): [in this window] [in a new window]   Fig. 2. View of the repaired aortic valve through the scope before aortic unclamping. The three commissural annuloplasty sutures can be seen.

References

1. Duran C, Kumar N, Gometza B, Al Halees Z. Indications and limitations of aortic valve reconstruction. Ann Thorac Surg 1991;52:447-54.[Abstract/Free Full Text]
   
2. Cosgrove DM, Rosenkranz ER, Steward WJ, Hendren WG. Valvuloplasty for aortic insufficiency. J THORAC CARDIOVASC SURG 1991;102:571-7.[Abstract]
   
3. Austen WG, Shaw RS, Scannell JG, Thurlbeck WM. Post mortem study of the technique of aortic valvotomy in calcific aortic stenosis by quantitative examination of valvular function by perfusion. J THORAC SURG 1958;36:571-83.
   
4. Ebert PA, Morrow AG, Austen WG. A method for assessing the competency of the aortic valve during aortic valvuloplasty. J THORAC CARDIOVASC SURG 1963;45:368-71.
   
5. Hudspeth AS, Cardell AR. A method for testing aortic valvular function during open repair. J THORAC CARDIOVASC SURG 1963;45:813-6.
   

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mishal Ghandour Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ghandour, M. Articles by Duran, C. Search for Related Content PubMed PubMed Citation Articles by Ghandour, M. Articles by Duran, C.