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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4th Introductory Cardiothoracic Course - 2004
Ian W. Colquhoun
The AORTIC ROOT has four anatomic components:
SINGLE FUNCTIONAL UNIT
Anterior leaflet of the mitral valve
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.
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.
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.
It represents the terminal edge of the aortic root and it is constituted by the imaginary line that connects together the 3 commissures.
AA = STJ
BASE = Aortic Annulus (AA)
Anatomic and Echocardiographic Relationship Between the Components of the Normal Aortic Root
120 degree - LAX
fused commissures, heavy calcification, age 40-60
rheumatic fever history in ½
3-cusp valve, no commissural fusion
MILD AS >1.2cm2
MODERATE 1.0 – 1.2 cm2
SEVERE 0.8 – 1.2 cm2
increased wall stress, decreased ejection fraction
reduced coronary reserve, subendocardial ischaemia
Higher preload required
Left atrial hypertrophy, prominent “a” wave
Loss of sinus rhythm – serious clinical deterioration
Echocardiogram with Doppler
a) HAEMODYNAMICALLY SEVERE (symptomatic or asymptomatic)
· Sudden death risk high· Immediate operation is indicated
b) HAEMODYNAMICALLY MILD – MODERATE (asymptomatic)
· 50% event free for 4 years· Operation is not urgent, but patients should be followed carefully as the disease advances rapidly
c) HAEMODYNAMICALLY MILD – MODERATE (symptomatic)
· One-third will die within 4 years· Prompt operation is indicated
Sinotubular junction dilatation
Dilatation of the sinotubular junction displaces the commissures outward and prevents the aortic leaflets from coapting, with resulting central aortic insufficiency
Aortic root aneurysm:
ST junction dilatation
Sinuses of Valsalva aneurysm
It may be due to alteration of the valve, the ascending aorta or both.
Eponyms associate with AR
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
· 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
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
· 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
· 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
Leaflets and their coaptation area
Sinuses of Valsalva
Commissures “supra” valvular
Sinotubular junction apparatus
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
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%
· 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