The aortic root

The shape of the aortic valve leaflet was first described by Philiston [1] in the 4th century BC as semilunar, and in 1513 Leonardo da Vinci [3] depicted in a drawing the geometry of the orifice of an opened and closed aortic valve as triangular and with three adjacent hemispherical forms, respectively (Figs. 1–3). Valsalva described the aortic sinuses in 1740 and suggested that the coronary artery filling takes place in the sinuses during diastole [4]. Recent echocardiographic and computed tomographic descriptions of the aortic valve and root diseases [5, 6, 7] and their relationship to the coronary artery origins have documented the importance of imaging the aortic root and the impact on the technical artistry of aortic root replacement, valve-sparing surgery, and minimally invasive transcatheter aortic valve replacement (Figs. 4–7) [8, 9, 10, 11, 12]. In fact, 2.9% of adults older than 65 years have calcific aortic stenosis [7]. Open image in new window Fig. 1. Echocardiographic imaging of the aortic root: short and long axis view. a Short axis view: severe AS: AVA 0.5 cm2; b long axis view: aortic valve annulus ∅ 24 mm; c mild mitral regurgitation, moderate tricuspid regurgitation Open image in new window Fig. 2. Cardiac computed tomographic view of the aortic root: end-systolic phase. The anatomic relationship between the aortic annulus and the coronary artery are shown Open image in new window Fig. 3. a The aortic valve in systole. b Opened leaflets in a triangular configuration. c The aortic valve in diastole in a configuration of three adjacent hemispheric form Open image in new window Fig. 4. Cardiac computed tomographic view of the aortic root. a Annulus 26 mm, b distance to left main coronary artery: 16 mm, c distance to RCA 16 mm Open image in new window Fig. 5. a The Edwards Sapien transcatheter self-expandable pericardial valve. b Transapical implantation of the Edwards Sapien self-expandable sutureless pericardial valve in the aortic root Open image in new window Fig. 6. Transapical valve-in-valve implantation of Edwards Sapien valve in a bioprosthesis after structural valve deterioration. a Introduction of the unexpanded Edwards Sapien valve into the bioprosthesis after balloon dilatation. b Implanted self-expandable Edwards Sapien valve in the bioprosthesis Open image in new window Fig. 7. Synopsis of a symptomatic aortic stenosis for transcatheter aortic valve replacement (AVA aortic valve area, STS Society of Thoracic Surgeons, TEE transesophageal echocardiography, CT computed tomography, AVR aortic valve replacement, TAVR transapical aortic valve replacement, TFAVR transfemoral aortic valve replacement)