Functional and pathomorphological anatomy of the aortic valve and root for aortic valve sparing surgery in tricuspid and bicuspid aortic valves

Figures

• 

  Figure 1. El Khoury classification for AR. Solid black arrows indicate dilation of the respective aortic segment. Grey arrows indicate regurgitant jet. AR, aortic regurgitation; FAA, functional aortic annulus.

• 

  Figure 2. Areas of the aortic annulus at risk for dilation; intraoperative native valve and echocardiographic images showing respective morphology of regurgitant jets. (A) Red lines show muscular portion of mitral and AV annulus; yellow line shows fibrous portion of the intertrigonal fibrous body (as indicated by arrows). Leaflet prolapse develops more frequently at the muscular portion of mitral and aortic annulus: (B-D) prolapse of the right coronary leaflet (arrows) in TAVs; (E-G) prolapse of the fused cusp in right/left-coronary cusp fusion, where the main prolapse is in the right coronary portion of the fused cusp (arrows indicate prolapsing leaflet areas). AV, aortic valve; TAV, tricuspid aortic valve.

• 

  Figure 3. Topographic relationship between AVJ and VBR. AVJ, aorto-ventricular junction; VBR, virtual basal ring.

• 

  Figure 4. AVJ thickness; myocardial crescent; El-Khoury maneuver. (A,B) AVJ thickness. (C,D) Height of myocardial crescent of left and right coronary sinuses in BAV. (E,F) Deep aortic root dissection: El Khoury maneuver. AVJ, aorto-ventricular junction; BAV, bicuspid aortic valve.

• 

  Figure 5. Relationship between dilation of the FAA and free margin length. A prolapse can arise when the eH drops below 9 mm. This can occur when the abnormally diseased and stretched leaflets are resuspended in a graft with normal root dimensions. This can lead to a prolapse, which is remedied through elevation of eH by means of a central cusp plication. STJ, sino-tubular junction; eH, effective height; FAA, functional aortic annulus.

• 

  Figure 6. Aortic leaflet coaptation surface. The coaptation surface is composed of two adjacent areas called the lunule; each lunule extends from the nodulus of arantius to the commissure (area marked in blue).

• 

  Figure 7. Repair-oriented surgical classification for BAVs [De Kerchove/El Khoury/Schäfers’ classification (45)]. BAV, bicuspid aortic valve.

• 

  Figure 8. Type A: symmetric phenotype BAV. Anatomic features: no or minimal raphe; raphe height is low; complete cusp fusion; raphe fusion length = gH of fused cusp; symmetric cusps; 2 (or 3) symmetric sinuses. Repair level: “easy”. (A1-A3) Echocardiographic images. (B1-B3) Intraoperative valve assessment. BAV, bicuspid aortic valve; gH, geometric height.

• 

  Figure 9. Type B: asymmetric phenotype BAV. Anatomic features: intermediate raphe height; incomplete cusp fusion; raphe fusion length < gH of fused cusp; asymmetric cusps; 2 or 3 asymmetric sinuses. Repair level “intermediate”. (A1-A3) Echocardiographic images. (B1-B3) Intraoperative valve assessment. BAV, bicuspid aortic valve; gH, geometric height.

• 

  Figure 10. Type C: very asymmetric phenotype BAV. Anatomic features: raphe height approximates sino-tubular junction level; short cusp fusion length; fenestrated raphe can occur (chordal type); often appears as 3 cusps and 3 sinuses, which can resemble a TAV. Repair level: “expert”. (A1-A3) Echocardiographic images. (B1-B3) Intraoperative valve assessment. BAV, bicuspid aortic valve; TAV, tricuspid aortic valve.

• 

  Video. Functional and pathomorphological anatomy of the aortic valve and root for aortic valve sparing surgery in tricuspid and bicuspid aortic valves.