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AORTIC VALVE DISEASE. 4 th Introductory Cardiothoracic Course - 2004 Ian W. Colquhoun. ANATOMY. Aortic Root - Anatomy. The AORTIC ROOT has four anatomic components:. The aortic annulus or aortoventricular junction. The leaflets. SINGLE FUNCTIONAL UNIT.

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aortic valve disease


4th Introductory Cardiothoracic Course - 2004

Ian W. Colquhoun


Aortic Root - Anatomy

The AORTIC ROOT has four anatomic components:

  • The aortic annulus or aortoventricular junction
  • The leaflets


  • The aortic sinuses or sinuses of Valsalva
  • The sinotubular junction

Aortic Annulus (aortoventricular junction)




Sinotubular Junctinon

Fibrous tissue


Anterior leaflet of the mitral valve

Membranous septum

Normal: 55% 45%

Marfan/Bicuspid aortic valve: 65% 35%


The aortic root is in fibrous continuity with the anterior leaflet of the mitral valve and the membranous septum; connective tissue (fibrous strands) unites the aortic root to the interventricular septum.


Valve Leaflets

They are attached to the aortic root in a semilunar fashion

The triangular space underneath the leaflet (trigone) is part of the left ventricle.

The highest point of the trigone where the leaflets meet is called the commissure. The commissures are localised immediately below the Sinotubular Junction.

The 2 trigones underneath the commissures of the noncoronary leaflet are fibrous structures, whereas the other underneath the commissure between the right and the left leaflets is mostly a muscular structure.


Sinuses of Valsalva

The segment of the arterial wall of the aortic root delineated by a leaflet proximally and by the sinotubular junction distally is called the aortic sinus or sinus of Valsalva.

  • They are 3 elliptical inlets that have a very important role in the dynamics of circulation :
  • Guaranteeing coronary artery
  • perfusion during systole;
  • Creating eddies to close the
  • aortic leaflets during diastole

Sinotubular Junction

It represents the terminal edge of the aortic root and it is constituted by the imaginary line that connects together the 3 commissures.

Young adults






BASE = Aortic Annulus (AA)


Anatomic and Echocardiographic Relationship Between the Components of the Normal Aortic Root

120 degree - LAX



ST junction

Tubular aorta



  • Calcific Aortic Stenosis Congenitally bicuspid or unicuspid,

fused commissures, heavy calcification, age 40-60

1% Population

  • Rheumatic Aortic StenosisFibrous thickening, 3-cusp valve, mild calcification, commisural fusion,

rheumatic fever history in ½

  • Degenerative Aortic Stenosis Diffuse nodular calcification

3-cusp valve, no commissural fusion

levels of stenosis 1
Levels of stenosis (1)
      • Elfin-like facies
      • Hypervitaminosis D
      • Pulmonary stenoses – valvar & peripheral
      • Mesenteric artery stenosis
      • Thoracic aneurysm
levels of stenosis 2
Levels of stenosis (2)
      • 10% congenital AS
      • Presents <1year of age
      • 50% have other cardiac defects
    • HOCM
      • AV canal
      • Parachute deformity of mitral – fused papillary muscles
aortic stenosis pathophysiology
Aortic Stenosis: Pathophysiology
  • Normal valve area = 2.5 – 3.5 cm2
  • Gorlan Formula

MILD AS >1.2cm2

MODERATE 1.0 – 1.2 cm2

SEVERE 0.8 – 1.2 cm2

CRITICAL <0.8cm2

  • Severe AS & normal cardiao output = transvalvar gradient >50mmHg
  • Pressure overload
  • Concentric left ventricular hypertrophy

increased wall stress, decreased ejection fraction

reduced coronary reserve, subendocardial ischaemia

  • Increased LVEDP

Higher preload required

Left atrial hypertrophy, prominent “a” wave

Loss of sinus rhythm – serious clinical deterioration

  • Eventual failure and dilatation of LV
as clinical picture symptoms
AS: Clinical Picture Symptoms
  • Asymptomatic
  • Syncope
    • cerebral hypoperfusion vs. dysrhythmias
  • Angina
    • myocardial O2 supply/demand imbalance
  • Congestive Heart Failure
  • Sudden death
as diagnosis
AS: Diagnosis


  • Loud harsh crescendo-decrescendo murmur radiating to neck
  • Possible diastolic murmur (AI murmur)
  • Split S2, possible S4 with atrial hypertrophy
  • Prominent presystolic apical impulse
  • Diminished carotid upstroke


  • LVH
  • LA hypertrophy
  • conduction abnormalities
as diagnosis1
AS: Diagnosis


  • Left ventricular prominence with possible cardiomegaly
  • Calcifications at level of aortic valve

Echocardiogram with Doppler

Heart Catheterization

  • Coronary artery anatomy recommended for all pts
  • Visualization of aorta
  • Quantify gradient across valve
  • Calculate aortic valve area with Gorlan formula
  • Quantify aortic regurgitation
  • Assess mitral valve, regional wall motion disturbances, and left ventricular function
natural history stenosis
Natural History - Stenosis

a) HAEMODYNAMICALLY SEVERE (symptomatic or asymptomatic)

· Sudden death risk high· Immediate operation is indicated


· 50% event free for 4 years· Operation is not urgent, but patients should be followed carefully as the disease advances rapidly


· One-third will die within 4 years· Prompt operation is indicated

  • Natural History Progression average of 0.1cm2 per year
  • Onset of Symptoms correlates with mortality risk

AR : Pathophysiology

  • Cusp Perforation
  • Cusp Prolapse
  • Restrictive Motion
  • Sinotubular Junction Dilatation
  • Annulus Dilatation
  • Annulo-aortic Ectasia

AR due to Abnormalities of the Leaflets

Infective endocarditis


Iatrogenic cause

Cusp perforation


AR due to Abnormalities of the Leaflets

  • Excess of tissue
  • Disrupted commissure
  • Commissural malposition

Cusp prolapse


AR due to Abnormalities of the Leaflets

Fibrous thickening

Restrictive motion


AR - Abnormalities of the Aortic Wall

Sinotubular junction dilatation

Dilatation of the sinotubular junction displaces the commissures outward and prevents the aortic leaflets from coapting, with resulting central aortic insufficiency


AR - Abnormalities of the Aortic Wall

  • Marfan syndrome
  • Connective tissue diseases
  • Ventricular dilatation
  • Chronic hypertension



AI due to Abnormalities of the Aortic Wall

Aortic root aneurysm:

ST junction dilatation


Sinuses of Valsalva aneurysm

aortic regurgitation 1
Aortic Regurgitation (1)
    • Bicuspid valve
    • Supra-valvar stenosis
    • Supra-cristal VSD and right coronary prolapse
    • Sinus of Valsalva aneurysm
aortic regurgitation 2
Aortic Regurgitation (2)


  • VALVE - Cusp prolapse or cicatricial shortening of cusps with rolled edges
      • Rheumatic fever
      • Infective endocarditis
      • Rheumatoid disease
      • SLE
      • Hurler’s syndrome
  • AORTIC ROOT - Dilation of sinus aorta, failure of coaptation of cusps
      • Dissection
      • Syphilis
      • Cystic medial necrosis e.g Marfans – annulo-aortic ectasia
      • Arthritides with aortitis e.g. Ankylosing spondylitis
      • Hypertension
      • Trauma

Aortic Valve Insufficiency

It may be due to alteration of the valve, the ascending aorta or both.


  • Idiopathic degenerative disease
  • Aortic dissection
  • Calcific aortic disease
  • Myxomatous degeneration
  • Rheumatic or postinflammatory disease
  • Bicuspid aortic valve
  • Trauma
  • Infective endocarditis
  • Idiopathic dilatation of the aortic root
  • VSD of the membranous septum
  • Systemic diseases(Whipple
  • disease; Crohn’s disease;)
  • Aortitis(Syphilis, viral
  • syndromes; giant cell
  • arteritis;Takayasu disease;
  • Chronic systemic hypertension
  • Connective tissue disorders
  • (Marfan’s syndrome; Reiter’s
  • disease; Ehlers-Danlos
  • syndrome; Osteogenesis
  • imperfecta; Rheumatoid
  • arthritis syndrome; Ankylosing
  • Spondylitis; SLE;)

Aortic Valve Insufficiency

  • Annulus
    • Annulo-aortic ectasia
  • Leaflets
    • Prolapse
    • Degeneration
    • Infectious disease

Valve Sparing



  • Sinuses of Valsalva
    • Dilatation of one or more sinus
    • Ascending aorta dissection
  • Sinotubular Junction
    • Global dilatation (including ascending aorta)
ar diagnosis
AR - Diagnosis

Eponyms associate with AR

  • Austin-Flint murmur – vibrations of anterior mitral leaflet
  • Duroziez’s sign – ‘to and fro’ femoral artery murmur
  • Quincke’s pulse – capillary pulsation in finger tips
  • Traube’s sign – ‘pistol shot’ sound at femoral artery
  • De Musset’s sign – head bobbing
natural history incompetence
Natural History - Incompetence

a) Latent period to cardiac decompensation is long

· Sudden death is not common· Once deterioration begins, the LV fails rapidly

b) Symptomatic patient with CHF, angina, syncope

· Prompt operation is indicated

c) Asymptomatic patient

·Follow carefully for LV enlargement or decreased LV function by ECHO or MUGA· Operate at an appropriate time

associated coronary artery disease
Associated Coronary Artery Disease

· Treat significant coronary artery disease at the time of surgery even if asymptomatic

· CABG reduces risk of AVR and improves long-term survival

· Coronary angiography is indicated in all patients older than 45 years who will be having AVR

ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease).

Bonow RO, Carabello B, de Leon AC, Edmunds LH Jr, Fedderly BJ, Freed MD, Gaasch WH, McKay CR, Nishimura RA, O'Gara PT, O'Rourke RA, Rahimtoola SH, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Gibbons RJ, Russell RO, Ryan TJ, Smith SC Jr.

J Heart Valve Dis. 1998 Nov;7(6):672-707

management as

Mild – moderate stenosis

Medical follow up

Regular ECHO

Avoid strenuous exercise

Endocarditis prophylaxis

? Role for statins

Progress ~0.1cm2 per year



Angina, syncope, failure

Moderate AS + CAD

Reduced BP on exercise

Severe AS & reduced LV function

management ar

Calcium channel blocker

Regular ECHO

Avoid isometric exercise

Endocarditis prophylaxis

Monitor for symptoms

Protracted course



Symptom onset

Asymptomatic if:

LVESD > 50-55mm

LVEDD > 70-75mm

LVEF < 55%

age and avr
Age and AVR

· Advanced age most common predictor of survival and cardiac events· AVR very effective treatment even in patients over age 70 or 80· Even the best patients over age 80 have reduced reserve

trends in choice of prosthesis
Trends in choice of prosthesis

· Age less than 55 years - Aortic allograft or pulmonary autograft

· Age between 55-75 years - Mechanical prosthesis

· Age greater than 75 years - Porcine heterograft, stented or stentless

· Allografts and autografts enlarge the orifice by about 2 mm, porcine heterografts reduce valve size by about 2 mm, and mechanical valves reduce valve size by about 5-8 mm

operative principles
Operative Principles
  • Restore unimpeded flow through aortic annulus / left ventricular outflow tract
  • Remove stenosis / regurgitation
  • Match valve size to patient
  • Repair / replace abnormal aorta ± reimplantation of coronary arteries
  • Concomitant pathology addressed:


Mitral valve

  • Inadequate decalcification
  • Too vigorous decalcification
  • Heart block from suture
  • Coronary ostial occlusion from sewing ring
  • Debris lodging in Left coronary ostium
operative results
Operative Results
  • Increased risk if
    • Emergency
    • NYHA Class III – IV
    • >65 years old
    • Severe AS AVA<0.7 or AVG>70, LVEDP>20
    • Impaired LV systolic function
    • Need for other procedure (CABG)
    • Renal dysfunction
    • Small BSA
    • Redo operation
  • Post op complications:
    • Operative mortality: ~ 5%
    • Complete heart block
    • Ischemic heart disease (6 months from coronary ostial stenosis)
    • CVA 3 – 5%
long term survival
Long term survival
  • 5 year survival
    • Normal LV function: 96%
  • Overall
    • 80% @ 5 years
    • 60% @ 10 years
    • Depressed LV function: 63%
  • Valve related morbidity responsible for >50% late deaths
  • Bioprosthetic valve - Reoperation:
        • 25% @ 10 years
        • 65% @ 15 years

Function of the Aortic Root

  • The function of the aortic valve is related to the integrity of:

 Leaflets and their coaptation area

 Annulus

 Sinuses of Valsalva

 Commissures  “supra” valvular

 Sinotubular junction  apparatus

patient prosthesis mismatch
Patient -Prosthesis Mismatch

Understand the concepts of EFFECTIVE ORIFICE AREA rather than VALVE SIZE

Not all similarly labelled valves are the same!!

a) “19 mm”· Prohibitively high LV/Ao gradient· Enlarge the aortic root or perform stentless / Ross procedure instead

b) “21 mm”· Adequate size if BSA 1.5-1.7 M2 and patient is sedentary· If BSA greater than 1.7 M2 = enlarge the aortic root (10 year survival 80% vs 60%)

c) “23 mm or larger”· Acceptable LV/Ao gradient in all patients

survival after avr
Survival After AVR

a) Early (hospital) death - 3-6%

b) Time-related survival · 5 years - 75% · 10 years - 60% · 15 years - 40%

c) Mode of death · Early due to CHF, hemorrhage, infection, CVA · Sudden - 20% · Device related - 20%

risk factors for survival after avr
Risk Factors for Survival after AVR

· Advanced age

· Functional status (NHYA class)

· Depressed LV function (aortic incompetence)

· Coronary artery disease

· Presence of endocarditis

· Aneurysm of ascending aorta

· Mismatch of prosthesis and body size

the small aortic root 1
The Small Aortic Root (1)

Nick’s Procedure

Manougian Procedure

  • Upsize valve x1 or 2
  • Simplest technique
the small aortic root 2
The Small Aortic Root (2)

Konno Procedure

  • Upsize valve x2 or 3 sizes
  • Complex technique
  • Paediatric population