Ann Thorac Surg 2002;73:284-286
© 2002 The Society of Thoracic Surgeons
Case report
Aortoscopy: a less invasive intraoperative method to assess the aortic valve
Eduardo A. Tovar, MD*a,b,
Jon R. Sherman, MDc,
David M. Weinberg, MDc,
Yonghun C. Suh, MDc,
Ramesh H. Rathod, MDc,
Alan Borsari, MDc
a Department of Cardiothoracic Surgery, University of California, Irvine Medical Center, Orange, California, USA
b Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, California, USA
c Department of Cardiology, St. Jude Medical Center, Fullerton, California, USA
Accepted for publication April 17, 2001.
* Address reprint requests to Dr Tovar, 100 E Valencia Mesa Dr, Suite 301, Fullerton, CA 92835, USA
e-mail: etovarmd{at}aol.com
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Abstract
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Surgical management of mild aortic stenosis coexisting with severe coronary artery disease remains controversial. Direct examination of the aortic root under these circumstances may be decisive. At present, intraoperative assessment of the aortic valve requires an aortic incision which, in itself, may increase the risk of intraoperative complications, particularly when this portion of the aorta is needed to construct proximal graft anastomoses. We present a simple aortoscopic method for direct intraoperative assessment of the aortic valve while performing coronary bypass grafting that obviates the need for aortic incisions.
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Introduction
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Surgical management of mild aortic stenosis (AS), coexisting with severe coronary artery disease (CAD), remains controversial [1, 2]. Some of these patients will rapidly progress to severe AS and if replacement is not performed during the initial operation, they will be condemned to a risky and technically demanding aortic valve replacement (AVR) as a second cardiac operation [3]. Conversely, those patients whose aortic valve (AV) would not have deteriorated but who undergo a concomitant AVR are needlessly subjected to a riskier primary operation and prosthetic valve-related complications [4]. At present, examination of the aortic root requires an aortic incision. This incision in itself carries some degree of intraoperative risk, particularly when this portion of the aorta is needed to construct proximal graft anastomoses. Once the arteriotomy has been made, it may persuade the surgeon to proceed with replacement despite the absence of significant valvular pathology. We present a simple aortoscopic method that allows excellent intraoperative visualization of the AV while coronary artery bypass grafting (CABG) is being performed.
While performing coronary artery bypass surgery, with the aortic cross-clamp in place and a right superior pulmonary vein vent, two buttonhole arteriotomies are made in the aortic root. An 18-cm x 4-mm scope with a 30° wide-angle lens (Karl Storz Endoscopy-America, Inc, Culver City, CA) is passed through one of the arteriotomies and an irrigation and suction device through the other, alternating with a 2-mm probe used to manipulate the leaflets. Excellent imaging is usually achieved allowing evaluation of the leaflets, commissures, and coronary ostia. If the valve is abnormal, one proceeds with a traditional AVR. If the AV is judged to contain only minimal or no pathology, the proximal anastomoses are then constructed over the arteriotomies, and coronary artery bypass surgery is completed as usual.
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Case reports
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Patient 1
A 70-year-old diabetic woman was referred for surgery. An echocardiogram showed a decreased left ventricular function with an ejection fraction of 39%, anteroseptal wall akinesis, and AS with a 63 mm Hg peak-to-peak gradient. A coronary angiogram depicted an occluded left anterior descending and severe triple vessel disease. The left ventriculogram was consistent with the echocardiographic findings. The gradient across the AV, however, was only 10 mm Hg. The patient underwent a quadruple CABG using the left internal thoracic artery, two radial artery grafts, and a saphenous vein graft. The aorta was small, had a thrill, and showed no post-stenotic dilatation. Aortoscopy revealed a trileaflet AV with no commissural fusion and only mild calcification at the base of the left coronary cusp (Fig 1).
Once the need for an AVR was ruled-out, a third punch arteriotomy was performed, the proximal anastomoses were completed, and the aortic cross-clamp removed. The patient recovered and continues to do well at 1 year in follow-up without significant increases in her transvalvular gradient.
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Fig 1. Aortoscopic picture of a trileaflet aortic valve without evidence of commissural fusion or calcification.
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Patient 2
A 69-year-old woman with unstable angina and hypertension was referred for coronary revascularization for severe diffuse triple vessel disease. The patient had history of reflux esophagitis, intermittent melenic stools, and anemia. Upper endoscopy revealed esophagitis and lower endoscopy showed multiple bright red, intramucosal, slightly elevated lesions diagnostic of angiodysplasia. In addition, the patient had moderate aortic stenosis with a 30 mm Hg gradient by catheter and 50 by Doppler echocardiography. The patient underwent a sextuple CABG and aortoscopic evaluation of the AV. The right and left coronary cusps appeared normal, the noncoronary cusp, however, revealed significant calcification (Fig 2).
An AVR was thus performed with a bioprosthesis. The patient recovered well and has not had any episodes of melenic stools at 6 months in follow-up; when last tested, her hemoglobin was normal (12.6 gm/dL), confirming the diagnosis of Heyde’s syndrome.
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Fig 2. Noncoronary cusp elevated by a probe reveals a thick calcified area on the ventricular surface (arrow). The other two leaflets appear normal.
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Patient 3
A 77-year-old man with a remote history of a laryngectomy for carcinoma of the larynx and a permanent tracheostomy was admitted with crescendo angina pectoris. The patient underwent a heart catheterization coronary and carotid angiography which revealed severe triple vessel disease, an ejection fraction of 73%, and a 95% lesion of the right internal carotid artery. That same day, the patient underwent a right carotid endarterectomy. The following morning, the patient became increasingly hypoxic and short of breath. A chest radiograph revealed pulmonary edema. An echocardiogram showed adequate ventricular function without wall motion abnormalities despite acute ischemic electrocardiographic changes and mild-to-moderate aortic insufficiency. The patient was intubated and taken to the operating room emergently for a triple-vessel CABG. Since the patient was not known to have AV pathology, an aortoscopy was performed and demonstrated a tear of the noncoronary cusp that, presumably, occurred during catheterization (Fig 3).
The patient underwent a combined AVR and CABG and recovered well.
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Fig 3. Torn commissural attachment of the noncoronary cusp (arrow) in an otherwise normally appearing aortic valve.
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Comment
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Currently, there is no reliable way to predict who, among those patients with mild AS and CAD, will develop a significant transvalvular gradient or the rate of progression [5]. A prospective randomized study is needed to clearly define the subset of patients who will benefit from a concomitant AVR during CABG [5]. In addition to echocardiographic examination, aortoscopic inspection of the AV may be useful in assessing these patients, particularly when no added morbidity will result from this intraoperative maneuver. Photographic records can be helpful in documenting anatomic characteristics of those valves that will deteriorate and those that will not. In addition, aortoscopy allows good visualization of the coronary ostia, the left ventricular outflow tract, and the subvalvular mitral apparatus [6]. In fact, this technology has already been applied in the management of hypertrophic cardiomyopathy [6] and in congenital heart disease [7]. Aortoscopy can also be used when transesophageal echocardiography is not readily available and there is a need to assess the AV on an emergency basis, as shown in patient 3. In summary, we present another example of a cardioscopic technique used, in this case, to evaluate and photographically document structural changes of the AV while performing CABG.
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References
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Abstract
Introduction
