Joseph S. Coselli, M.D. ? Surgical Anatomy of the Aortic Valve and Root AATS International Cardiovascular Symposium 2017 Session 6: Basic Principles of Aortic Valve Disease Sao Paulo, Brazil • Friday, December 8, 2017 Vice-Chair, Department of Surgery Professor, Chief, and Cullen Foundation Endowed Chair Division of Cardiothoracic Surgery Baylor College of Medicine
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Joseph S. Coselli, M.D.?
Surgical Anatomy of the Aortic Valve and Root
AATS International Cardiovascular Symposium 2017Session 6: Basic Principles of Aortic Valve Disease
Sao Paulo, Brazil • Friday, December 8, 2017
Vice-Chair, Department of SurgeryProfessor, Chief, and Cullen Foundation Endowed Chair
Division of Cardiothoracic SurgeryBaylor College of Medicine
Thubrikar, M.J. . The aortic valve. CRC Press (1990) pp. 11–20
Understanding AV and Root Geometry
Thubrikar, M.J. . The aortic valve. CRC Press (1990) pp. 11–20
Understanding AV and Root GeometryRIDICULOUS
The Aortic Root
A Dynamic Structure
5 Key Components:
• Sino-Tubular Junction• Sinuses of Valsalva• Annulus• Sub Aortic Segment• Aortic Leaflets
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What is the definition of aortic root?
Basal attachment of aortic valve leaflets
Sinutubular junction
Parasternal Long Axis
Left ventricle
Aorta
Root extends from the basal attachments of the aortic valve leaflets (green line) to the sinutubular junction (blue line)
Slide courtesy of Nicolo Piazza, MDAnderson MMCTS 2006
Aorticsinus
Surgical Anatomy• Aortic root is
anchored between the pulmonary root anteriorly and mitral and tricuspid posteriorly
• Fibrous skeleton of the heart
Pulmonaryvalve/root
Aorticvalve/root
Posteromedial trigone (right)
Carpentier’s Reconstructive Valve Surgery Ch 5, 2010
Diastole shown
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1: Sinutubular Junction
“Crown” formed by attachment of semilunar valve leaflets
2: Anatomic ventriculo-aortic junction
3: Virtual basal ring“echo” annulus
Membranousseptum
Aorta
Slide courtesy of Nicolo Piazza, MDAnderson MMCTS 2006
Aortic Root: Crown and 3 “Rings”
1
3
2
Sinuses of Valsalva
Anterolateral trigone
Aorto-mitral curtainMitral valve
Posteromedial trigone
Membranous septum
Annulus
Scallop-shaped fibrous structure attached to the trigones the aorto- mitral curtain and the muscular and membranous septa.
Aortic Root Function
Early systole Late systole Diastole
Sinuses of Valsalva
Collagen → Elastin• More collagen at base• Progressive increase in elastic lamellae superiorly as approach sinutubular junction
Antonio Maria Valsalva 1666-1723
Sinuses of Valsalva
• When pressurized, the sinutubular junction is larger than that of annulus 1 : 1.3 ratio of diameters
• When not under pressure, the annulus is larger than sinutubular junction 1 : 1.15 ratio of diameters
Antonio Maria Valsalva 1666-1723
Sinuses of Valsalva: Role?“The aortic sinuses have no effective on valve competence, but are important in reducing mechanical stress on the aortic cusps during the cardiac cycles by creating eddies and currents between the cusps and the sinus walls.”T. David Nat. Rev. Cardiol 2013
Furukawa ATS 1999Bellhouse Nature 1968
De Paulis ATS 2001Aybek JHVD 2005
Flexible Heart Valves Modeled Using FIDAPSchool of Mechanical Engineering, University of Leeds
Sinuses of Valsalva
Sinuses of Valsalva
Force (stress) = Pressure x Area
The Sinuses of ValsalvaCoronary Artery Positions.Distance from nadir (mm)Smallest
Largest
Left coronary sinus
Right coronarysinus
LCA RCAPost-Mortem (n=51)Arq Bras Cardio 2003;81:359
12.6 ± 2.6 mm 13.2 ± 2.6 mm
MSCT (n=169)JACC Img 2008;1:321-330
14.4 ± 2.9 mm 17.2 ± 3.3 mm
Angiography (n=63)Rotterdam experience
13.6 ± 2.2 mm 15.7 ± 2.3 mm25
Aortic Root: Coronary Ostia
Average HeightConsiderable Variation
Nicolo Piazza, MD Anderson MMCTS 2006
Sub Aortic Segment
Left bundle branch
Right coronary arteryLeft coronaryartery
Tricuspid valve
MembranousseptumNon-coronary sinus
AV node
Mitral valve
Right fibrous trigone
Aortic Leaflets
Coaptingsurfaces
BellyHingeAnnulus
Valve Leaflet Properties• Fibrous core (spongiosa and fibrosa)
covered by fibroelastic layer on arterial and ventricular sides
• Less elastin than ascending aorta but surprisingly elastic
• Loose gelatinous layer, the spongiosa, is sandwiched by two fibrous layers