Nomenclature of the components of the aortic root

We read with considerable interest the recent editorial by Lansac and de Kerchove [1] regarding the ‘state of the art’ procedures in the repair of the aortic root. We hesitate to question the content of the editorial, but we wonder whether they do justice to the naming of the components of the arterial roots? As was revealed by a questionnaire survey conducted by Sievers et al. [2], the current description of these components represents a ‘Tower of Babel’ concern. In their otherwise excellent editorial, Lansac and de Kerchove add to the confusion. Thus, throughout their article, they describe the moving components of the root as the ‘cusps’. As emphasized by Sievers et al. [2], the vernacular meaning of ‘cusp’ is ‘a pointed end and where two curves meet’. The component of the root that best meets this definition is the area that is currently described by Lansac and de Kerchove [1] as the commissure. Those answering the questionnaire, by a small majority, preferred the term ‘leaflet’ when describing the moving components of the roots [2]. As was then emphasized by Sievers et al. [2], ‘the term “leaflet” should be preferred’ because ‘the term “cusp” may lead to no significant misinterpretation’. Many physicians, furthermore, use ‘cusp’ to describe the valvar sinuses rather than the leaflets. Nowhere in their editorial, however, do Lansac and de Kerchove [1] seek to distinguish between the valvar leaflets and their supporting sinuses. It is the anatomy of the supporting sinuses that produces the key features of the aortic root, namely the crossing of the semilunar hinges relative to the anatomic ventriculo-arterial junction at the bases of the 2 aortic sinuses which give rise to the coronary arteries. Because of this arrangement, small crescents of the myocardium are incorporated at the bases of these sinuses [3]. Lansac and de Kerchove are then in error when suggesting that the virtual basal plane is the same locus as the ‘aortoventricular junction’. Virtual dissection of computed tomographic datasets has shown that the anatomic aortoventricular junction is distal relative to the virtual basal place in the 2 sinuses that give rise to the coronary arteries [3]. Questions also remain as to whether the ‘unicuspid and unicommissural’ aortic valve should be considered a variant of the ‘bicuspid’ valve. It is the presence of interleaflet triangles on the ventricular aspect of the arterial root that serves to distinguish between bisinuate aortic valves, as opposed to trisinuate valves that are bicuspid. In the latter situation, virtual dissection shows 1 interleaflet triangle to be grossly hypoplastic [4]. In the unicuspid and unicommissural valve, 2 of the interleaflet triangles are hypoplastic. This shows that the valves are trisinuate but unicuspid [5]. In making these comments, we do not wish to detract from the importance of the editorial of Lansac and de Kerchove. The burgeoning era of virtual dissection of computed tomographic datasets, nonetheless, now points to the evidence leading to deconstruction of the Tower of Babel, because the anatomic features are now obvious [3, 4].