anatomie of the av & root - uniklinikum-saarland.de · functional aortic annulus •ring-like...
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Anatomy of the
Aortic Valve & Root
Reconstruction of the
Aortic Valve and Root
Sept 12-14, 2018
Frank Langer
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Aortic Valve/Root Anatomy
• Location / Co-Location
•Anatomic Components
• Dimensions
• Congenital Variations
• Failure Modes
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Aortic Root: Location
• Posterior / right relative
to the subpulmonary
infundibulum
• Wedged between the
orifices of the two AV-
valves
Anderson Heart 2000
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Co-Location
Wilcox Cook Anderson Cambridge 3rd ed
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Anatomical Aortic Annulus
• Unites aortic cusps and sinuses
• Scalloped shape
• Fibrous throughout its course
• Strands extend into myocardium and the fibrous continuity with AML Crown-shaped hemodynamic
junction marked by semilunar
attachments of the aortic cusps
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Functional Aortic Annulus
• Ring-like anatomical ventriculo-arterial junction
• Ring-like joining base line of semilunar attachments
(virtual) basal ring
Anderson Heart 2000
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Basal Ring = AV-junction
Crescents of LV musculature
at base of left and right sinus
(variable)Anderson Heart 2000
AV junction
Muscle within
the sinus
Basal ringleft sinus
Morphometric study (BAV)
right sinus
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Aortic Cusps
• Consist of collagen, elastin, glycosaminoglycans
• Attached to (anatomical) aortic annulus
• Cusps meet at commissures below sinotubular
junction
• Semilunar shape - base 1.5 x free margin
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Swanson Clark CIRC Res 1973
Dimensions: Valve / Root
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Dimensions: Root
Kunzelman, Grande, David et. al JTCVS 1994
10 normal cryopreserved
tricuspid homografts
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Dimensions: Cusps
Kunzelman, Grande, David et. al JTCVS 1994
a2 +b2=c2 c=√(a2 +b2)
e.g. 122 +102=c2 c=√(244)=15.62
a
bc
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Schäfers JTCVS 2013
Dimensions: Cusps
Geometric height measured intraoperatively in 621 patients:
BAV non-fused cusp 23.8 ± 2.0 mm
TAV NCC 20.7 ± 2.2 mm, LCC & RCC 20.0 ± 2.1 mm
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De Kerchove Eur JCTS 2017
Dimensions: Cusps
Geometric height measured in 25 fresh tricuspid aortic root homografts
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Bierbach Eur JCTS 2010
Cusp Configuration
Effective height measured in TTE:
130 healthy volunteers
(100 adults, 30 children)
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Bierbach Eur JCTS 2010
Cusp Configuration
Swanson Clark CIRC Res 1973 De Kerchove Eur JCTS 2017
eH = 0.45-0.5 x gH
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Congenital Variations
Roberts CIRC 2005
TAV BAV UAV QAV ?
45 % 49 % 5 %
Valve specimens after AVR
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Congenital Variations: BAV
• Prevalence 1 – 2 %
•Aortopathy in (40 –) 60 %Nistri Heart 1999
Masri Heart 2017
Cusp fusion Commissural orientation
Partial Fusion Complete Fusion
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Congenital Variations: BAV
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Congenital Variations: UAV
• Prevalence 0,02 %
• Unicommissural variant:
1 fully developed commissure
commonly in posterior location
rudimentary commissures lower
congenital fusion:
RCC-LCC
RCC-NCC
• Acommissural variant (rare)
• Critical AS in infancy or childhood
•AS or AR in 3rd or 4th decade of life
• Prevalence of aortopathy ?
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Congenital Variations: UAV
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Congenital Variations
Sievers JTCVS 2007
• Type 0 and 1 = bicuspid
• Type 1: commissural orientation ? fusion complete / partial ?
• Type 2 = unicuspid
?
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Congenital Variations: QAV
• Prevalence 0,01 - 0,04 %
• Seven different types (A-G)
• LCA displaced leftward/upward
•AR in 5th or 6th decade of life
•AS rare
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Congenital Variations: QAV
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Failure Modes in AR
• prolapse
• retraction
• aortic dilatation
• prolapse of fused cusp
• annular dilatation
• commissural height
• annular dilatation
• restriction
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Conclusions
• The normal aortic valve function depends on
correct interactions between root and cusp
configuration.
• Different morphological cusp variants exist and may
lead to aortic valve dysfunction.
• In reconstruction of the aortic valve the different
cusp configurations and failure modes have to be
considered as part of the repair strategy.