A Geometric Model of the Normal Human Aortic Root and Design of a Fully Anatomic Aortic Root Graft

Objective Available aortic root grafts generally flare outward in the sinus region, and this feature improves procedural ease. However, no current device is based on normal aortic root geometry, and a fully anatomic aortic root graft could further facilitate valve-sparing root operations. Methods To develop a model of the normal human aortic root, high-resolution computed tomographic angiogram images from 11 normal human aortas generated high-density x, y, z coordinates of valve and root structures in Mathematica. Three-dimensional least-squares regression analyses assessed geometry of the aortic valve and root. Shapes and dimensions were quantified, and minor variations in geometry were simplified during graft design. Results Normal aortic valve and root geometry was represented as three leaflet-sinus general ellipsoids nested within a cylindrical aorta. Sinotubular junction diameter was 5 mm larger than the valve base—with a slight funnel-shaped outward commissural flare but cylindrical geometry above the midvalve. The valve base was elliptical, but the midvalve and the sinotubular junction were circular above the midvalve level. Commissural locations on the base circumference were equidistant. On the basis of average three-dimensional geometry, a root graft was designed for root remodeling procedures—to be used with an internal geometric annuloplasty ring of the same design. Conclusions An aortic root graft was designed on the basis of mathematical analyses of computed tomographic angiogram images. The design incorporated three anatomic sinuses, commissural symmetry, and compatibility with geometric ring annuloplasty. The anatomic graft may prove useful for restoring aortic root geometry toward normal during aortic valve and root surgery.

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Design Characteristics of a Three-Dimensional Geometric Aortic Valve Annuloplasty Ring

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000026 ◽

2013 ◽

Vol 8 (5) ◽

pp. 364-370 ◽

Cited By ~ 9

Author(s):

Philip S. Crooke ◽

L. Alan Beavan ◽

Charles D. Griffin ◽

Domenico Mazzitelli ◽

J. Scott Rankin

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

Three Dimensional ◽

Diameter Ratio ◽

Aortic Valve Repair ◽

Least Squares Regression ◽

Valve Repair ◽

Annuloplasty Ring ◽

Computed Tomographic ◽

Root Area

Objective A full geometric annuloplasty ring could facilitate aortic valve repair. The purpose of this report was to document the design of such a ring using mathematical analyses of normal human aortic valve computed tomographic angiograms. Methods One-millimeter axial slices of high-resolution computed tomographic angiograms from 11 normal aortic roots were used to generate high-density x, y, and z coordinates of valve structures in Mathematica. Three-dimensional least squares regression analyses of leaflet-sinus coordinates were used to assess geometry of aortic valve and root structures. Results Normal valve geometry could be represented as three leaflet-sinus general ellipsoids nested within an elliptical aortic root. Minor-major diameter ratio of the valve base was 0.60 ± 0.07, and elliptical geometry extended vertically up the commissures. By contrast, leaflet-sinus horizontal circumferences were fairly circular (diameter ratios, 0.82–0.87), and the left coronary/noncoronary commissural post was located at the posterior base minor diameter-circumference junction, with the center of the right coronary leaflet opposite. Post location on the circumference was symmetrical, with a deviation of only ±2% to ±3% from 33.3% symmetry. Commissural posts flared outward by 5 to 10 degrees, and leaflet areas were statistically equivalent ( P > 0.10). From end diastole to midsystole, the aortic root became less elliptical (diameter ratio increased by 0.15), but root area expanded minimally (less than +5%). A one-piece rigid annuloplasty ring was designed with 2:3 base ellipticality, three 10-degree outwardly flaring symmetrical posts, and post height = base circumference/2π. Conclusions A three-dimensional aortic annuloplasty ring was designed that could prove useful for enhancing applicability and stability of aortic valve repair.

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Three-dimensional aortic root reconstruction derived from rotational angiography for transcatheter balloon-expandable aortic valve implantation guidance

International Journal of Cardiology ◽

10.1016/j.ijcard.2014.07.152 ◽

2014 ◽

Vol 176 (3) ◽

pp. 1318-1320 ◽

Cited By ~ 3

Author(s):

Mariam Samim ◽

Pierfrancesco Agostoni ◽

Freek Nijhoff ◽

Ricardo P.J. Budde ◽

Alferso C. Abrahams ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

Three Dimensional ◽

Rotational Angiography ◽

Aortic Valve Implantation ◽

Valve Implantation

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Aortic root dynamics and surgery: from craft to science

Philosophical Transactions of the Royal Society B Biological Sciences ◽

10.1098/rstb.2007.2124 ◽

2007 ◽

Vol 362 (1484) ◽

pp. 1407-1419 ◽

Cited By ~ 48

Author(s):

Allen Cheng ◽

Paul Dagum ◽

D. Craig Miller

Keyword(s):

Aortic Valve ◽

Fifteenth Century ◽

Aortic Root ◽

Cardiac Cycle ◽

Three Dimensional ◽

Future Research ◽

Root Dynamics ◽

Post Intervention ◽

Structural Valve Deterioration ◽

Root Deformation

Since the fifteenth century beginning with Leonardo da Vinci's studies, the precise structure and functional dynamics of the aortic root throughout the cardiac cycle continues to elude investigators. The last five decades of experimental work have contributed substantially to our current understanding of aortic root dynamics. In this article, we review and summarize the relevant structural analyses, using radiopaque markers and sonomicrometric crystals, concerning aortic root three-dimensional deformations and describe aortic root dynamics in detail throughout the cardiac cycle. We then compare data between different studies and discuss the mechanisms responsible for the modes of aortic root deformation, including the haemodynamics, anatomical and temporal determinants of those deformations. These modes of aortic root deformation are closely coupled to maximize ejection, optimize transvalvular ejection haemodynamics and—perhaps most importantly—reduce stress on the aortic valve cusps by optimal diastolic load sharing and minimizing transvalvular turbulence throughout the cardiac cycle. This more comprehensive understanding of aortic root mechanics and physiology will contribute to improved medical and surgical treatment methods, enhanced therapeutic decision making and better post-intervention care of patients. With a better understanding of aortic root physiology, future research on aortic valve repair and replacement should take into account the integrated structural and functional asymmetry of aortic root dynamics to minimize stress on the aortic cusps in order to prevent premature structural valve deterioration.

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Faculty Opinions recommendation of Three-dimensional transoesophageal echocardiography of the aortic valve and root: changes in aortic root dilation and aortic regurgitation.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.726738296.793523346 ◽

2016 ◽

Author(s):

John Augoustides

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Aortic Root ◽

Three Dimensional ◽

Transoesophageal Echocardiography

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A Geometric Model of the Normal Human Aortic Root and Design of a Fully Anatomic Aortic Root Graft

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/155698451501000110 ◽

2015 ◽

Vol 10 (1) ◽

pp. 57-62

Author(s):

Philip S. Crooke ◽

L. Alan Beavan ◽

Charles D. Griffin ◽

Domenico Mazzitelli ◽

J. Scott Rankin

Keyword(s):

Aortic Root ◽

Geometric Model ◽

Normal Human

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Quantitative three‐dimensional echocardiographic analysis of the bicuspid aortic valve and aortic root: A single modality approach

Journal of Cardiac Surgery ◽

10.1111/jocs.14387 ◽

2019 ◽

Vol 35 (2) ◽

pp. 375-382

Author(s):

Melissa M. Levack ◽

Gianclaudio Mecozzi ◽

Jayant S. Jainandunsing ◽

Wobbe Bouma ◽

Arminder S. Jassar ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Root ◽

Three Dimensional ◽

Modality Approach ◽

Single Modality

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Sex differences in aortic root and vascular anatomy in patients undergoing transcatheter aortic valve implantation: A computed-tomographic study

Journal of Cardiovascular Computed Tomography ◽

10.1016/j.jcct.2017.01.006 ◽

2017 ◽

Vol 11 (2) ◽

pp. 87-96 ◽

Cited By ~ 11

Author(s):

Ashraf Hamdan ◽

Israel Barbash ◽

Ehud Schwammenthal ◽

Amit Segev ◽

Ran Kornowski ◽

...

Keyword(s):

Sex Differences ◽

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Aortic Root ◽

Vascular Anatomy ◽

Computed Tomographic ◽

Transcatheter Aortic Valve ◽

Aortic Valve Implantation ◽

Valve Implantation

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Three-dimensional imaging of the aortic valve and aortic root with computed tomography: new standards in an era of transcatheter valve repair/implantation

European Heart Journal ◽

10.1093/eurheartj/ehp260 ◽

2009 ◽

Vol 30 (17) ◽

pp. 2079-2086 ◽

Cited By ~ 70

Author(s):

P. Schoenhagen ◽

E. M. Tuzcu ◽

S. R. Kapadia ◽

M. Y. Desai ◽

L. G. Svensson

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Aortic Root ◽

Three Dimensional ◽

Valve Repair ◽

Three Dimensional Imaging ◽

Transcatheter Valve

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Partial Aortic Root Remodeling in Case of Ascending Aortic Aneurysms

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e3182a754b6 ◽

2013 ◽

Vol 8 (4) ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Fabrizio Sansone ◽

Edoardo Zingarelli ◽

Fabrizio Ceresa ◽

Francesco Patanè

Keyword(s):

Aortic Root ◽

Pathological Process ◽

Ascending Aorta ◽

Aortic Aneurysms ◽

Bleeding Complications ◽

Sinotubular Junction ◽

Computed Tomographic ◽

Aortic Root Remodeling ◽

Aorta Replacement ◽

Ascending Aorta Replacement

Objective In degenerative ascending aortic aneurysms (AAAs), the pathological process may extend into the aortic root, causing aortic regurgitation (AR). As often one or two sinuses are involved, ascending aorta replacement should be associated with selected sinus replacement. Methods Thirty patients (21 men and 9 women; mean ± SD age, 70.0 ± 10.4) were operated on for ascending aorta and selected sinus replacement. All patients had degenerative AAA with sinotubular junction and partial root dilatation: one or two sinuses of Valsalva were involved. Mild to moderate-severe AR was present in all patients. The mean ± SD logistic EUROscore 1 was 15.4 ± 12.5. Twenty patients had ascending aorta replacement associated with noncoronary sinus replacement; 8 patients, associated with both right and noncoronary sinuses; 1 patient, associated with both left and noncoronary sinuses; and 1 patient, associated with left coronary sinus alone. Results There were no hospital or late deaths. No thromboembolic event or bleeding complications were reported. Postoperative echocardiography did not show significant AR, and computed tomographic scanning revealed a normal positioning of the vascular graft in the ascending aorta. Conclusions Remodeling of the sinotubular junction with selected sinus replacement in degenerative AAA is a valuable approach for aortic root remodeling, leading to a significant reduction of AR when the aortic leaflets are normal.

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