The Sinotubular Junction-to-Aortic Annulus Ratio as a Determinant of Supravalvar Aortic Stenosis Severity.

Supravalvar aortic stenosis (SVAS) severity guides management, including decisions for surgery. Physiologic and technical factors limit the determination of SVAS severity by Doppler echocardiography and cardiac catheterization in Williams syndrome (WS). We hypothesized SVAS severity could be determined by the sinotubular junction-to-aortic annulus ratio (STJ:An). We reviewed all preintervention echocardiograms in patients with WS with SVAS cared for at our center. We measured STJ, An, peak and mean Doppler gradients, and calculated STJ:An. We created 2 mean gradient prediction models. Model 1 used the simplified Bernoulli's equation, and model 2 used computational fluid dynamics (CFD). We compared STJ:An to Doppler-derived and CFD gradients. We reviewed catheterization gradients and the waveforms and analyzed gradient variability. We analyzed 168 echocardiograms in 54 children (58% male, median age at scan 1.2 years, interquartile range [IQR] 0.5 to 3.6, median echocardiograms 2, IQR 1 to 4). Median SVAS peak Doppler gradient was 24 mm Hg (IQR 14 to 46.5). Median SVAS mean Doppler gradient was 11 mm Hg (IQR 6 to 21). Median STJ:An was 0.76 (IQR 0.63 to 0.84). Model 1 underpredicted clinical gradients. Model 2 correlated well with STJ:An through all severity ranges and demonstrated increased pressure recovery distance with decreased STJ:An. The median potential variability in catheterization-derived gradients in a given patient was 14.5 mm Hg (IQR 7.5 to 19.3). SVAS severity in WS can be accurately assessed using STJ:An. CFD predicts clinical data well through all SVAS severity levels. STJ:An is independent of physiologic state and has fewer technical limitations than Doppler echocardiography and catheterization. STJ:An could augment traditional methods in guiding surgical management decisions.

In vitro evaluation of a new aortic valved conduit.

BACKGROUND: This study examined whether the presence of a sinus of Valsalva equivalent in the KONECT RESILIA aortic valved conduit (Edwards Lifesciences, Irvine, Calif) improves valve hemodynamics, kinematics, and performance. METHODS: A 28-mm KONECT RESILIA aortic valved conduit was used to create an in vitro flow test model, and the same aortic valved conduit model without a sinus section was used as a control. Particle image velocimetry and hydrodynamic characterization experiments were conducted in the vicinity of the valves in a validated left-heart simulator at 3 cardiac output levels. In addition, leaflet kinematics of the valves were determined through en face high-speed imaging. RESULTS: The KONECT RESILIA aortic valved conduit model exhibited lower mean and peak transvalvular pressure gradients than the control model at all 3 cardiac outputs. In addition, its leaflets opened more fully than did those of the valved conduit without the sinuses, yielding greater effective and geometric orifice areas. It was found that the presence of the sinuses not only facilitated the development of larger and more stable vortices at the initial stages of the cardiac cycle but also helped to maintain these vortices during the late stages of the cardiac cycle, leading to smoother valve closure. CONCLUSIONS: The KONECT RESILIA aortic valved conduit reproduces the bulged section of the aortic root corresponding to the sinuses of Valsalva. With this Valsalva-type conduit, larger orifice areas were observed, improving valve hemodynamics that may enhance performance.

Morphology of Sinus of Valsalva After Aortic Valve-Sparing Root Replacement Using Valsalva Graft.

Utilization of the Gelweave Valsalva graft (Terumo Vascutek, Tokyo, Japan) for David-type valve-sparing aortic root replacement was still controversial because this prosthesis did not completely reproduce the native sinus of Valsalva. We focused on the morphology of pseudo-Valsalva sinus after the reimplantation procedure and evaluated our novel crimp plication stitch from the viewpoint of morphology of Valsalva sinus at midterm follow-up periods.

Variant origin and course of left circumflex coronary artery.

Variant origin of left circumflex coronary artery (LCx) from right aortic sinus is a well-recognized coronary variation, usually without any clinical consequences. However, the variant origin and trajectory of the artery may have major implications during percutaneous coronary intervention, coronary artery surgery, aortic and mitral valve replacement procedures. We observed a variant LCx in a heart specimen belonging to 45-year-female with no history of hypertension, diabetes mellitus and coronary artery disease. The artery arose along with the right coronary artery from a common ostium in right aortic sinus and depicted a retroaortic course. The vessel was located at the level of aortic annulus and 6.6 mm above mitral valve annulus. The degree of luminal stenosis in variant LCx was higher than that in right coronary artery (RCA) and left anterior descending artery (LAD). Appropriate anatomical knowledge of the location and course of variant LCx is important for successful coronary interventions and valve replacement procedures.

Double non coronary aortic sinuses: an autopsy case finding showing the arterial variation / Senos aórticos dobles, no coronarios: un caso de autopsia que demuestra la variación arterial

We report a case of variant origin of the right coronary artery from the left posterior aortic sinus. This was observed routinely during a medico legal autopsy of a 58 year old male who died in a road traffic accident. Initially it was believed that the right coronary artery was absent since there was no obvious right coronary artery ostium from the anterior aortic sinus. However it was found later that the right coronary ostium was present just beside the left coronary ostium in the left posterior aortic sinus and the right coronary artery was arising from the left posterior aortic sinus. The right coronary artery had an intramural course between the aorta and pulmonary trunk, which is considered as very dangerous and life threatening. We believe that the present case report will be enlightening to the cardiologist and cardiothoracic surgeon. It is also true that the conduction of medico legal autopsies of coronary arteries is important for the medico legal resolution.

Se presenta un caso de variación de origen de la arteria coronaria derecha desde el seno aórtico posterior izquierdo. Esto se observó de forma rutinaria durante una autopsia médico-legal de un hombre de 58 años que murió en un accidente de tránsito. Inicialmente se creía que la arteria coronaria derecha estaba ausente ya que no había un ostium observable desde el seno aórtico anterior. Sin embargo, se descubrió más tarde que el ostium de la arteria coronaria derecha estaba presente justo al lado del ostium de la arteria coronaria izquierda en el seno aórtico posterior izquierdo y la arteria coronaria derecha se originaba del seno aórtico posterior izquierdo. La arteria coronaria derecha presentó un recorrido intramural entre la aorta y el tronco pulmonar, que se considera como muy peligroso y potencialmente mortal. Creemos que el presente trabajo será esclarecedor para el cardiólogo y el cirujano cardiotorácico. También consideramos que el conocimiento de la anatomía de las arterias coronarias es importante durante el desarrollo de la autopsia médico-legal para lograr alcanzar una correcta resolución del proceso medicolegal.

Comparison of mechanical properties of human ascending aorta and aortic sinuses.

BACKGROUND: Computational finite element models of the aortic root have previously used material properties of the ascending aorta to describe both aortic sinuses and ascending aorta. We have previously demonstrated significant material property differences between ascending aorta and sinuses in pigs. However, it is unknown whether these regional material property differences exist in humans. The main objective of this study was to investigate biomechanics of fresh human ascending aorta and aortic sinuses and compare nonlinear material properties of these regions. METHODS: Fresh human aortic root specimens obtained from the California Transplant Donor Network (Oakland, CA) were subjected to displacement-controlled equibiaxial stretch testing within 24 hours of harvest. Stress-strain data recorded were used to derive strain energy functions for each region. Tissue behavior was quantified by tissue stiffness and a direct comparison was made between different regions of aortic root at physiologic stress levels. RESULTS: All regions demonstrated a nonlinear response to strain during stretch testing in both circumferential and longitudinal directions. No significant difference in tissue stiffness was found between anterior and posterior regions of the ascending aorta or among the three sinuses in both directions. However, our results demonstrated that human ascending aorta is significantly more compliant than aortic sinuses in both circumferential and longitudinal directions within the physiologic stress range. CONCLUSIONS: Significant material and structural differences were observed between human ascending aorta and aortic sinuses. Regionally specific material properties should be employed in computational models used to assess treatments of structural aortic root disease.

Dynamic normal aortic root diameters: implications for aortic root reconstruction.

BACKGROUND: The main aim of this study is to determine the normal diameter and the relationship of aortic root components in healthy adults, and to provide a morphologic foundation for future clinical applications. METHODS: Echocardiography was performed in 314 normal subjects who were divided into five groups according to age. Dynamic aortic root diameters were measured and normalized to body surface area. Averages of these dynamic diameters were calculated for each age group and by gender, and differences between them were tested. Correlation coefficients were also determined between the dynamic diameters and age, body surface area, weight, and height. Aortic root diameters were also tested and compared between the end-diastole and the mid-systole. RESULTS: Normalized diameters for the dynamic aortic root varied among the age groups. There were apparent relationships between the dynamic diameters and age, body surface area, weight, and height (p < 0.01). The normalized diameters were similar between both genders within each age group (p > 0.05). Each part of the aortic root expanded and contracted proportionally and harmoniously during the cardiac cycle. The ratio of the aortic valve annulus to the sinus of Valsalva, the sinus-tube joint, and the proximal ascending aorta were 0.70, 0.85, and 0.78 at the end-diastole, respectively, and 0.71, 0.85 and 0.78 at the mid-systole, respectively. CONCLUSIONS: The dynamic diameters of aortic roots of healthy adults were augmented with an increase according to age, body surface area, weight, and height. The results are of applicable value to aortic valve repair.

Significant differences in the material properties between aged human and porcine aortic tissues.

OBJECTIVE: Currently, percutaneous aortic valve (PAV) replacement devices are being investigated to treat aortic stenosis in patients deemed to be of too high a risk for conventional open-chest surgery. Successful PAV deployment and function are heavily reliant on the tissue-stent interaction. Many PAV feasibility trials have been conducted with porcine models under the assumption that these tissues are similar to human; however, this assumption may not be valid. The goal of this study was to characterize and compare the biomechanical properties of aged human and porcine aortic tissues. METHODS: The biaxial mechanical properties of the left coronary sinus, right coronary sinus, non-coronary sinus, and ascending aorta of eight aged human (90.1 ± 6.8 years) and 10 porcine (6-9 months) hearts were quantified. Tissue structure was analyzed via histological techniques. RESULTS: Aged human aortic tissues were significantly stiffer than the corresponding porcine tissues in both the circumferential and longitudinal directions (p < 0.001). In addition, the nearly linear stress-strain behavior of the porcine tissues, compared with the highly nonlinear response of the human tissues at a low strain range, suggested structural differences between the aortic tissues from these two species. Histological analysis revealed that porcine samples were composed of more elastin and less collagen fibers than the respective human samples. CONCLUSIONS: Significant material and structural differences were observed between the human and porcine tissues, which raise questions on the validity of using porcine models to investigate the biomechanics involved in PAV intervention.

[Atrial tachycardia ablated from the non-coronary aortic cusp]. / Ablacja czestoskurczu przedsionkowego w niewiencowej zatoce aorty.

We present a case of a patient with drug resistant atrial tachycardia which was ablated from the noncoronary aortic cusp. Tachycardia was adenosine-sensitive and was characterized by a long RP' interval and low amplitude P waves (biphasic in II, III, aVF and V1-V2 leads, and positive in aVL). The earliest atrial activation during tachycardia was recorded at His region and from non-coronary aortic sinus of Valsalva. RF ablation at this area terminated tachycardia and did not impair atrio-ventricular conduction.

Aneurysm of the sinus of valsalva.

Aneurysms of the sinus of Valsalva (ASVs) are rare. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-occur with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. Although unruptured ASVs are usually asymptomatic, ruptured ASVs often cause symptoms similar to those of heart failure and produce a continuous, mechanical-sounding murmur. Transsternal or transesophageal echocardiography is usually effective in detecting ASVs. Because symptomatic ASVs pose significant risks for the patient, and because the repair of asymptomatic ASVs generally produces excellent outcomes, surgery is indicated in most cases. The primary goals of surgical repair are to close the ASV securely, remove or obliterate the aneurysmal sac, and repair any associated defects. Operative mortality is generally low except in patients with concomitant bacterial endocarditis or other infections. Late events are uncommon and tend to be related to aortic valve prothesis or Marfan syndrome.

The ideal theoretical graft oversizing in valve-sparing aortic operations with a standard tubular or a Valsalva graft.

OBJECTIVE: We sought to determine, by a mathematical model, the ideal theoretical degree of ascending aortic graft oversizing needed to obtain normal sinuses dimension in the reimplantation type of valve-sparing aortic operations. METHODS: To define a normal-range value, size of sinuses of Valsalva was conventionally expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area (BLA), and measured in 50 healthy subjects. A mathematical relationship between aortic annulus diameter, aortic sinuses diameter and resulting BLA was defined. By simulating intra-operative scenarios, the effect of different degrees of a standard or Valsalva graft oversizing on BLA extension was tested. RESULTS: The same degree of graft oversizing resulted in a bigger beyond leaflets area for the Valsalva graft than for a standard graft. Oversizing degrees exceeding +7mm for a standard graft and +3mm for the Valsalva graft resulted in a beyond leaflets area over normal limits. Results were expressed in a visual form as two different normograms, one for the standard graft and one for the Valsalva graft. CONCLUSIONS: A less pronounced graft oversizing is needed to achieve normal-range sinuses size when using a Valsalva graft, the ideal theoretical graft oversizing was +7mm for a standard graft and +3mm for the Valsalva graft, our normograms can be helpful in selecting a proper graft size when performing a valve-sparing aortic procedure.

Anatomic three-dimensional echocardiographic correlation of bicuspid aortic valve.

This study was undertaken to verify the echocardiographic characteristics of bicuspid aortic valve (AV) using 3-dimensional transesophageal echocardiography by comparing the findings with anatomic examination of autopsy specimens from carriers of this condition. Three-dimensional reconstructions of transesophageal echocardiograms were performed on 14 patients with bicuspid AV, and 20 autopsy specimens of bicuspid AVs were analyzed. Echocardiographic images and autopsy material were correlated. Two variants of bicuspid aorta were identified. In group I the AV had 2 leaflets. This group included 9 (9/14) 3-dimensional echocardiographic studies and 13 (13/20) necropsies. In group II 3 sigmoid leaflets had originally developed and 2 underwent dysplastic fusion, resulting in functionally bicuspid valves. Five (5/14) echocardiographic studies and 7 (7/20) anatomic specimens fell into this category. There was a clear correspondence between anatomic and echocardiographic findings, which leads to the conclusion that 3-dimensional echocardiography is a technique that reliably defines the morphological details of bicuspid AV with the precision of anatomopathologic examination.

The anatomy of the aortic root.

OBJECTIVE: Since the aortic root preserving methods are spreading in heart surgery, the importance of aortic root anatomy is increasing. The surgical and anatomical descriptions of the aortic root are not always congruent. Therefore, the present study focuses on the surgical aspects of the aortic root anatomy. METHODS: We measured the distances between the three commissures, the distances between the basal point of the sinus and the sinotubular junction and the heights of the sinuses. The circumference of the sinotubular junction and the annuli fibrosi were also obtained. In addition, the volume of every sinus was directly measured. Finally both vertical and horizontal histological sections of annuli fibrosi were made. RESULTS: All measured parameters were averaged and the standard deviation (SD) was calculated, except in the case of the tilt angle. The distance for the right sinus commissures was 18.82 mm (SD 1.93 mm), and that of the non- and left coronary sinus were 17.43 (SD 2.06) and 15.21 (SD 1.88) mm, respectively. The mean height of the right, non- and left coronary sinus were 19.45 (SD 1.91), 17.68 (SD 1.77) and 17.45 (SD 1.39) mm, respectively. These differences between the height of the sinuses determines a mean tilt angle of 5.47 degrees for the sinotubular junction and aortic root base. The mean circumference of the aortic root base and of the sinotubular junction was 69.20 (SD 6.93), and 65.82 (SD 8.31) mm, respectively. Mean volumes of the right, non- and left coronary sinuses were 1.6 (SD 0.34), 1.33 (SD 0.27) and 1.04 (SD 0.23l) ml. According to the histological sections we can say that the histological border of the annuli fibrosi is positioned at the interleaflate triangles. CONCLUSION: According to the measured data we can state that all parameters follow the pattern in which the right sinus structures had the greatest dimensions followed by the non coronary sinus, and finally the left coronary sinus. The tilt angle for aortic root base and sinotubular junction, and the difference in the diameters could be of hemodynamic and of surgical relevance

The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve.

Surgical descriptions of the aortic root are not always in keeping with anatomy as observed in the autopsied heart. Although all surgeons appreciate that the concept of the aortic annulus does not imply the presence of a straight ring as a hinge point, the nature of the supporting fibrous structures relative to the semilunar attachment of the leaflets has yet to be clarified. We have analyzed 50 normal aortic roots, two fetal aortic roots sectioned histologically in horizontal and sagittal planes, respectively, and two autopsied adult hearts in which prosthetic aortic valves had been inserted during life. Our results demonstrate the important interrelationships between aortic sinuses, valvar leaflets, and supporting left ventricular structures that produce the three fibrous interleaflet triangles. It is the structure and location of these triangles that is the key to the understanding of the surgical anatomy. Our results also show that the presently used definition of commissure does not reflect adequately the extent of the zones of apposition between adjacent valvar leaflets, essential for normal function when the valve is closed.

Leonardo da Vinci and the sinuses of Valsalva.

Recent studies indicate that eddy currents generated by the sinuses of Valsalva play an important role in the physiologic closure of the aortic valve. This process is briefly discussed and evidence is presented that this fact was well known and elaborated upon by the renaissance artist Leonardo da Vinci. This fact is illustrated with his words and drawings.

Development of the coronary arteries in staged human embryos: the Paris embryological collection revisited

Twenty seven human embryos from stages 15 to 23 (postsomitic period), belonging to the collection of the "UFR Biomédicale des Saints-Peres, Université René Descartes Paris V", were studied. Details of the aorticopulmonary cleavage were analysed specially aortic valve development and origin of the coronary artery. At stage 18 the aortic valve was clearly distinguished (cup-shaped) presenting semilunar valves and aortic sinus (Valsalvae); at this stage the left coronary artery was detected in 66.7 per cent of the cases as an endothelial epicardial invagination. At stage 19, the left and right coronary arteries were detected simultaneously in 100 per cent of the cases. At stage 20, the coronary arteries showed greater structural complexity with a coat of mesenchymal cells. These results agree with previous data from different embryological collections. These findings suggest that the left coronary artery has a tendency to develop earlier than the right. We found no evidence of the coronary origin from the aortic umen. This work provides additional information about the embryological development of the heart, obtained from the analyses of a French collection of human embryos

Relación entre ostios coronarios y senos aórticos / Relation between coronay ostium and aortic sinus

La descripción topográfica de los ostios coronarios es de gran importancia anátomo-clínica, por el uso de ellos en la cateterización exitosa en una arteriografía coronaria selectiva (Sones 1962). En ocasiones las variaciones de ubicación de los ostios con respecto a los senos, crea dificultades técnicas y requiere una mayor manipulación del cateter o bien el uso de catéteres especiales (Amplatz et al., 1967). Se analiza la disposición de los ostios de las arterias coronarias en 40 individuos chilenos, cuyas edades fluctúan entre 18 y 73 años, siendo 34 del sexo masculino y 6 del sexo femenino. Las muestras fueron obtenidas en el Servicio de Anatomía Patológica, Medicina Legal y Unidad de Anatomía Normal, Universidad de la Frontera, Temuco. Las variables analizadas son: número de ostios, diámetro de ellos, relación con el seno aórtico respecto al plano vertical y plano horizontal. Los resultados obtenidos son comparados con los realizados por otros autores como Banchi (1904); Rocha Lagoa (1928); Testut y Latarjet (1958); James (1961); Paulin (1964) y Vladover (1972)