Anatomy (real anatomy) of the aortic valve replacement: when we can actually see it

Cardiac surgeons perform a number of procedures in the aortic outflow tract, the so named “aortic annulus” and the surrounding structures. This region has many structures related to the conduction system, like the atrioventricular node, the His bundle and its branches, plus the vascular supply of these elements. There are several “dogmas” regarding valve replacement procedures that preclude any stitch from going “near”, “under”, “beneath”, etc. some specific zones; most of the time this dogmas are followed without reaching comprehensive understanding of the milimetric nature of the “play-field” when performing an aortic or mitral procedure. The detailed anatomy of the subaortic outflow tract is clearly illustrated by the pictures accompanying this paper. There are not “schematic drawings” in this paper. All of the pictures are photographs of human hearts where dissection of the conduction system and its blood supply was performed. Some of the hearts were subjected to true cardiac procedures in vivo, and the dissection of the His bundle was performed postmortem. This study reveals the precise location of the subaortic structures evidencing the real manoeuvre margin that the surgeon has in stented-valve, nostented-valve, Bentall and homografts procedures.