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Anatomy of the aortic root: implications for aortic root reconstruction

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Abstract

Since the introduction of valve-preserving root replacement and aortic annuloplasty, precise understanding of the aortic root anatomy has emerged as a key to successful aortic valve-preservation surgery. Fundamentally, surgeons need to know the precise anatomical definition and structure of the aortic root, including its normal dimensions, know the anatomy of the coronary arteries, and understand the cardiac conduction system. Surgeons must be able to clearly distinguish normal and abnormal structures, and recognize the effects of aortic valve regurgitation or root expansion on dimensions and geometric relationships within the aortic root. Possessing a detailed understanding of the aortic root, surgeons can select appropriately sized grafts and achieve optimum annular fixation. This review covers the essentials of aortic root anatomy and provides tips for correct and safe performance of aortic valve-preservation surgery with a view toward durable late outcomes.

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References

  1. Wheat MW Jr, Wilson JR, Bartley TD. Successful replacement of the entire ascending aorta and aortic valve. JAMA. 1964;188:717–9.

    Article  Google Scholar 

  2. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23:338–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. David TE, Feindel CM. An aortic-valve sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617–22.

    CAS  PubMed  Google Scholar 

  4. Sarsam MA, Yacoub M. Remodeling of the aortic anulus. J Thorac Cardiovasc Surg. 1993;105:435–8.

    CAS  PubMed  Google Scholar 

  5. Sud A, Parker F, Magilligan DJ Jr. Anatomy of the aortic root. Ann Thorac Surg. 1984;38:76–9.

    Article  CAS  Google Scholar 

  6. Patel PA, Gutsche JT, Vernick WJ, Giri JS, Ghadimi K, Weiss SJ, Jagasia DH, Bavaria JE, Augoustides JG. The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer. J Cardiothorac Vasc Anesth. 2015;29:240–5.

    Article  PubMed  Google Scholar 

  7. Bierbach BO, Aicher D, Issa OA, Bomberg H, Gräber S, Glombitza P, Schäfers HJ. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg. 2010;38:400–6.

    Article  Google Scholar 

  8. Sievers HH, Hemmer W, Beyersdorf F, Moritz A, Moosdorf R, Lichtenberg A, Misfeld M, Charitos EI, Working Group for Aortic Valve Surgery of German Society of Thoracic and Cardiovascular Surgery. The everyday used nomenclature of the aortic root components: the tower of Babel? Eur J Cardiothorac Surg. 2012;41:478–82.

    Article  PubMed  Google Scholar 

  9. Sands MP, Rittenhouse EA, Mohri H, Merendino KA. An anatomical comparison of human pig, calf, and sheep aortic valves. Ann Thorac Surg. 1969;8:407–14.

    Article  CAS  PubMed  Google Scholar 

  10. Lehmkuhl L, Foldyna B, Von Aspern K, Lücke C, Grothoff M, Nitzsche S, Kempfert J, Haensig M, Rastan A, Walther T, Mohr FW, Gutberlet M. Inter-individual variance and cardiac cycle dependency of aortic root dimensions and shape as assessed by ECG-gated multi-slice computed tomography in patients with severe aortic stenosis prior to transcatheter aortic valve implantation: is it crucial for correct sizing? Int J Cardiovasc Imaging. 2013;29:693–703.

    Article  PubMed  Google Scholar 

  11. Erasmi A, Sievers HH, Scharfschwerdt M, Eckel T, Misfeld M. In vitro hydrodynamics, cusp-bending deformation, and root distensibility for different types of aortic valve-sparing operations: remodeling, sinus prosthesis, and reimplantation. J Thorac Cardiovasc Surg. 2005;130:1044–9.

    Article  Google Scholar 

  12. Anderson RH, Devine WA, Ho SY, Smith A, McKay R. The myth of the aortic annulus: the anatomy of the subaortic outflow tract. Ann Thorac Surg. 1991;52:640–6.

    Article  CAS  Google Scholar 

  13. Sutton JP 3rd, Ho SY, Anderson RH. The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve. Ann Thorac Surg. 1995;59:419–27.

    Article  PubMed  Google Scholar 

  14. David TE. Aortic root aneurysms: remodeling or composite replacement? Ann Thorac Surg. 1997;64:1564–8.

    Article  CAS  PubMed  Google Scholar 

  15. Wuliya M, Sleilaty G, Di Centa I, Khelil N, Berrebi A, Czitrom D, Mankoubi L, Noghin M, Malergue MC, Chatellier G, Debauchez M, Lansac E. An expansible aortic ring to preserve aortic root dynamics after aortic valve repair. Eur J Cardiothorac Surg. 2015;47:482–90.

    Article  PubMed  Google Scholar 

  16. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg. 1994;107:162–70.

    CAS  PubMed  Google Scholar 

  17. Matsumori M, Tanaka H, Kawanishi Y, Onishi T, Nakagiri K, Yamashita T, Okada K, Okita Y. Comparison of distensibility of the aortic root and cusp motion after aortic root replacement with two reimplantation techniques: valsalva graft versus tube graft. Interact Cardiovasc Thorac Surg. 2007;6:177–81.

    Article  PubMed  Google Scholar 

  18. Anderson RH. Clinical anatomy of the aortic root. Heart. 2000;84:670–3.

    Article  CAS  PubMed Central  Google Scholar 

  19. de Kerchove L, El Khoury G. Anatomy and pathophysiology of the ventriculo-aortic junction: implication in aortic valve repair surgery. Ann Cardiothorac Surg. 2013;2:57–64.

    PubMed  PubMed Central  Google Scholar 

  20. Khelil N, Sleilaty G, Palladino M, Fouda M, Escande R, Debauchez M, Di Centa I, Lansac E. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg. 2015;99:1220–6.

    Article  PubMed  Google Scholar 

  21. de Kerchove L, Jashari R, Boodhwani M, Duy KT, Lengelé B, Gianello P, Nezhad ZM, Astarci P, Noirhomme P, El Khoury G. Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and aortic valve annuloplasty. J Thorac Cardiovasc Surg. 2015;149:425–33.

    Article  PubMed  Google Scholar 

  22. Carpentier A, et al. Carpentier’s reconstructive valve surgery. New York: Saunders Elsevier; 2010.

    Google Scholar 

  23. Villa AD, Sammut E, Nair A, Rajani R, Bonamini R, Chiribiri A. Coronary artery anomalies overview: the normal and the abnormal. World J Radiol. 2016;8:537–55.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kaku B. Clinical features and prognosis of patients with anomalous origin of the coronary artery. J Juzen Med Soc. 1996;105:496–505.

    Google Scholar 

  25. Cademartiri F, La Grutta L, Malago R, Alberghina F, Meijboom WB, Pugliese F, Maffei E, Palumbo AA, Aldrovandi A, Fusaro M, Brambilla V, Coruzzi P, Midiri M, Mollet NR, Krestin GP. Prevalence of anatomical variants and coronary anomalies in 543 consecutive patients studied with 64-slice CT coronary angiography. Eur Radiol. 2008;18:781–91.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Anderson RH. The surgical anatomy of the aortic root. Multimed Man Cardiothorac Surg. 2007;2007(102):mmcts.2006.002527.

  27. Swanson M, Clark RE. Dimensions and geometric relationships of the human aortic valve as a function of pressure. Circ Res. 1974;35:871–82.

    Article  CAS  PubMed  Google Scholar 

  28. Schäfers HJ, Aicher D, Riodionycheva S, Lindinger A, Rädle-Hurst T, Langer F, Abdul-Khaliq H. Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg. 2008;85:2012–8.

    Article  Google Scholar 

  29. Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg. 2007;133:1226–33.

    Article  PubMed  Google Scholar 

  30. Kim M, Roman MJ, Cavallini MC, Schwartz JE, Pickering TG, Devereux RB. Effect of hypertension on aortic root size and prevalence of aortic regurgitation. Hypertension. 1996;28:47–52.

    Article  CAS  PubMed  Google Scholar 

  31. D’Andrea A, Cocchia R, Riegler L, Scarafile R, Salerno G, Gravino R, Vriz O, Citro R, Limongelli G, Di Salvo G, Cuomo S, Caso P, Russo MG, Calabrò R, Bossone E. Aortic root dimensions in elite athletes. Am J Cardiol. 2010;105:1629–34.

    Article  Google Scholar 

  32. Roman MJ, Devereux RB, Kramer-Fox R, O’Loughlin J. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol. 1989;64:507–12.

    Article  CAS  PubMed  Google Scholar 

  33. Padial LR, Oliver A, Sagie A, Weyman AE, King ME, Levine RA. Two-dimensional echocardiographic assessment of the progression of aortic root size in 127 patients with chronic aortic regurgitation: role of the supraaortic ridge and relation to the progression of the lesion. Am Heart J. 1997;134:814–21.

    Article  CAS  PubMed  Google Scholar 

  34. Capps SB, Elkins RC, Fronk DM. Body surface area as a predictor of aortic and pulmonary valve diameter. J Thorac Cardiovasc Surg. 2000;119:975–82.

    Article  CAS  PubMed  Google Scholar 

  35. Calleja A, Thavendiranathan P, Ionasec RI, Houle H, Liu S, Voigt I, Sai Sudhakar C, Crestanello J, Ryan T, Vannan MA. Automated quantitative 3-dimensional modeling of the aortic valve and root by 3-dimensional transesophageal echocardiography in normals, aortic regurgitation, and aortic stenosis: comparison to computed tomography in normals and clinical implications. Circ Cardiovasc Imaging. 2013;6:99–108.

    Article  PubMed  Google Scholar 

  36. Tops LF, Wood DA, Delgado V, Schuijf JD, Mayo JR, Pasupati S, Lamers FP, van der Wall EE, Schalij MJ, Webb JG, Bax JJ. Noninvasive evaluation of the aortic root with multislice computed tomography implications for transcatheter aortic valve replacement. JACC Cardiovasc Imaging. 2008;1:321–30.

    Article  PubMed  Google Scholar 

  37. Delgado V, Ng AC, van de Veire NR, van der Kley F, Schuijf JD, Tops LF, de Weger A, Tavilla G, de Roos A, Kroft LJ, Schalij MJ, Bax JJ. Transcatheter aortic valve implantation: role of multi-detector row computed tomography to evaluate prosthesis positioning and deployment in relation to valve function. Eur Heart J. 2010;31:1114–23.

    Article  Google Scholar 

  38. Rankin JS, Bone MC, Fries PM, Aicher D, Schäfers HJ, Crooke PS. A refined hemispheric model of normal human aortic valve and root geometry. J Thorac Cardiovasc Surg. 2013;146:103–8.

    Article  PubMed  Google Scholar 

  39. Schäfers HJ, Schmied W, Marom G, Aicher D. Cusp height in aortic valves. J Thorac Cardiovasc Surg. 2013;146:269–74.

    Article  PubMed  Google Scholar 

  40. Morishita K, Murakami G, Koshino T, Fukada J, Fujisawa Y, Mawatari T, Abe T. Aortic root remodeling operation: how do we tailor a tube graft? Ann Thorac Surg. 2002;73:1117–21.

    Article  PubMed  Google Scholar 

  41. Contino M, Mangini A, Lemma MG, Romagnoni C, Zerbi P, Gelpi G, Antona C. A geometric approach to aortic root surgical anatomy. Eur J Cardiothorac Surg. 2016;49:93–100.

    Article  PubMed  Google Scholar 

  42. Mangini A, Lemma MG, Soncini M, Votta E, Contino M, Vismara R, Redaelli A, Antona C. The aortic interleaflet triangles annuloplasty: a multidisciplinary appraisal. Eur J Cardiothorac Surg. 2011;40:851–7.

    PubMed  Google Scholar 

  43. Aicher D, Kunihara T, Abou Issa O, Brittner B, Gräber S, Schäfers HJ. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011;123:178–85.

    Article  PubMed  Google Scholar 

  44. Navarra E, El Khoury G, Glineur D, Boodhwani M, Van Dyck M, Vanoverschelde JL, Noirhomme P, de Kerchove L. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg. 2013;44:316–22.

    Article  PubMed  Google Scholar 

  45. de Kerchove L, Mastrobuoni S, Boodhwani M, Astarci P, Rubay J, Poncelet A, Vanoverschelde JL, Noirhomme P, El Khoury G. The role of annular dimension and annuloplasty in tricuspid aortic valve repair. Eur J Cardiothorac Surg. 2016;49:428–37.

    Article  PubMed  Google Scholar 

  46. Izumoto H, Kawazoe K, Oka T, Kazui T, Kawase T, Nasu M. Aortic valve repair for aortic regurgitation: intermediate-term results in patients with tricuspid morphology. J Heart Valve Dis. 2006;15:169–73.

    Google Scholar 

  47. Marom G, Halevi R, Haj-Ali R, Rosenfeld M, Schäfers HJ, Raanani E. Numerical model of the aortic root and valve: optimization of graft size and sinotubular junction to annulus ratio. J Thorac Cardiovasc Surg. 2013;146:1227–31.

    Article  PubMed  Google Scholar 

  48. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg. 1998;115:1080–90.

    Article  CAS  PubMed  Google Scholar 

  49. David TE, Feindel CM, Armstrong S, Maganti M. Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to treat aortic insufficiency in patients with ascending aortic aneurysm. J Thorac Cardiovasc Surg. 2007;133:414–8.

    Article  Google Scholar 

  50. de Kerchove L, Boodhwani M, Glineur D, Noirhomme P, El Khoury G. A new simple and objective method for graft sizing in valve-sparing root replacement using the reimplantation technique. Ann Thorac Surg. 2011;92:749–51.

    Article  PubMed  Google Scholar 

  51. David TE. Sizing and tailoring the Dacron graft for reimplantation of the aortic valve. J Thorac Cardiovasc Surg. 2005;130:243–4.

    Article  PubMed  Google Scholar 

  52. Morishita K, Abe T, Fukada J, Sato H, Shiiku C. A surgical method for selecting appropriate size of graft in aortic root remodeling. Ann Thorac Surg. 1998;65:1795–6.

    Article  CAS  PubMed  Google Scholar 

  53. Svensson LG, Cooper M, Batizy LH, Nowicki ER. Simplified david reimplantation with reduction of anular size and creation of artificial sinuses. Ann Thorac Surg. 2010;89:1443–7.

    Article  PubMed  Google Scholar 

  54. David TE. Additional anatomic information on the aortic root. J Thorac Cardiovasc Surg. 2015;149:408–10.

    Article  PubMed  Google Scholar 

  55. Richardt D, Karluss A, Schmidtke C, Sievers HH, Scharfschwerdt M. A new sinus prosthesis for aortic valve-sparing surgery maintaining the shape of the root at systemic pressure. Ann Thorac Surg. 2010;89:943–6.

    Article  PubMed  Google Scholar 

  56. Scharfschwerdt M, Leonhard M, Lehmann J, Richardt D, Goldmann H, Sievers HH. In vitro investigation of a novel elastic vascular prosthesis for valve-sparing aortic root and ascending aorta replacement. Eur J Cardiothorac Surg. 2016;49:1370–3.

    Article  PubMed  Google Scholar 

  57. El Khoury GA, Underwood MJ, Glineur D, Derouck D, Dion RA. Reconstruction of the ascending aorta and aortic root: experience in 45 consecutive patients. Ann Thorac Surg. 2000;70:1246–50.

    Article  PubMed  Google Scholar 

  58. Schäfers HJ, Raddatz A, Schmied W, Takahashi H, Miura Y, Kunihara T, Aicher D. Reexamining remodeling. J Thorac Cardiovasc Surg. 2015;149:S30–6.

    Article  Google Scholar 

  59. Lansac E, Di Centa I, Vojacek J, Nijs J, Hlubocky J, Mecozzi G, Debauchez M. Valve sparing root replacement: the remodeling technique with external ring annuloplasty. Ann Cardiothorac Surg. 2013;2:117–23.

    PubMed  PubMed Central  Google Scholar 

  60. Jeanmart H, de Kerchove L, Glineur D, Goffinet JM, Rougui I, Van Dyck M, Noirhomme P, El Khoury G. Aortic valve repair: the functional approach to leaflet prolapse and valve-sparing surgery. Ann Thorac Surg. 2007;83:S746–51.

    Article  PubMed  Google Scholar 

  61. Holubec T, Higashigaito K, Belobradek Z, Dergel M, Harrer J, Alkadhi H, Zacek P, Vojacek J. An expansible aortic ring in aortic root remodeling: exact position, pulsatility, effectiveness, and stability in three-dimensional CT study. Ann Thorac Surg. 2017;103:83–90.

    Article  PubMed  Google Scholar 

  62. Boodhwani M, El Khoury G. Aortic valve repair. Op Tech Thoracic Cardiovasc Surg. 2009;14:266–80.

    Article  Google Scholar 

  63. Schneider U, Aicher D, Miura Y, Schäfers HJ. Suture annuloplasty in aortic valve repair. Ann Thorac Surg. 2016;101:783–5.

    Article  PubMed  Google Scholar 

  64. Schneider U, Schmied W, Aicher D, Giebels C, Winter L, Schäfers HJ. Sinus plication to improve valve configuration in bicuspid aortic valve repair-early results. Ann Thorac Surg. 2017;103:580–5.

    Article  PubMed  Google Scholar 

  65. Izumoto H, Kawazoe K, Oka T, Ishibashi K, Yamamoto H, Yamamoto F. Leaflet suspension and subvalvular annuloplasty in aortic valve prolapse. Asian Cardiovasc Thorac Ann. 2009;17:278–81.

    Article  Google Scholar 

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kunihara, T. Anatomy of the aortic root: implications for aortic root reconstruction. Gen Thorac Cardiovasc Surg 65, 488–499 (2017). https://doi.org/10.1007/s11748-017-0792-y

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