Left Coronary Ostium Research Articles

Dramatik Tutulum! Takayasu Arteritine Bağlı Çoklu Damar Tutulumunun Eşlik Ettiği Sağ-Sol Koroner Ostial Darlıklı Bir Olgu

Takayasu arteritis is a chronic, idiopathic, inflammatory, systemic disease that primarily affects large vessels such as the aorta and its main branches. A 37-year-old woman who had 98% left coronary ostial stenosis and right coronary ostial stenosis due to Takayasu arteritis was recommended transaortic patch enlargement of the stenosed left coronary ostium and right coronary ostium. We believe that this technique is more suitable and recommendable than conventional coronary bypass for coronary ostial stenosis in cases with Takayasu arteritis.

Extracorporeal Membrane Oxygenation for Adults with ARDS-Current Evidence

Objective: To describe the first case of minimally invasive modified Bentall Operation done at our institution that resulted in an excellent outcome. Method: We describe a 28 year old Chinese male, without past medical history and risk factors, who presented with sudden shortness of breath on exertion associated with one month duration of lethargy and intermittent fever and was diagnosed with severe aortic regurgitation secondary to infective endocarditis on echocardiography. He was planned for a minimally invasive aortic valve replacement. Intra-operatively, the aortic wall was noted to be infected with vegetation in the background of bicuspid aortic valve and decision was made on table to perform minimally invasive modified Bentall Operation. He was also noted to have a rare presentation of rudimentary left coronary ostia, with only single right coronary ostia which supplies to the 3 coronary arteries. Results: The patient had an uncomplicated clinical course post-operatively and was discharged on post-operative day five in excellent condition. He was started on life-long anticoagulation. The patient was asymptomatic on follow-up and is progressing well. Conclusion: The initial surgical plan was for minimally invasive aortic valve replacement, but it was a decision made on table that changed to a minimally invasive modified Bentall Operation. The patient subsequently did well and benefitted from the advantages of a minimally invasive heart surgery.

Echocardiographic Diagnosis of Left Main Coronary Artery Atresia

This case describes an infantile presentation of left main coronary artery atresia (LMCAA), which involves complete absence of the left coronary ostium and left main coronary artery. The echocardiographic features of LMCAA that assist in making this diagnosis are detailed. Important imaging features that distinguish LMCAA from anomalous left coronary artery from the pulmonary artery are highlighted.

Location and Size of Coronary Ostia in Normal Autopsied Hearts at the University Teaching Hospital, Lusaka, Zambia

Background: Coronary ostia are orifices located in the aortic sinuses from which coronary arteries normally arise. Knowledge of their location and size is important in diagnosis and treatment cardiovascular diseases. Materials and methods: A total of 125 hearts were dissected and examined during autopsy to determine the size and location of the coronary ostia in the aortic sinus, sinu-tubular junction (STJ) or tubular part of the ascending aorta. Photographs of coronary ostia were taken and a Vernier caliper was used to measure ostia. Results: The right coronary ostium was located in the right aortic sinus 79.3% (96/121) and on the STJ in 20.7% (25/121) of the hearts. The left coronary ostium was located in the left aortic sinus in 73.6% (89/121) and on the STJ in 26.4% (32/121) of the hearts. The left coronary ostium width range was 1.6 – 7.9 mm (4.62 ± 1.104 mm) and the height range was 1.5 – 4.9 mm (2.64 ± 0.719 mm). The right coronary ostium width range was 1.6 – 9.6 mm(3.66 ± 1.40 mm) and the height range was 1.1 – 4.9 mm (2.27 ± 0.72 mm).The estimated mean cross sectional area of the left coronary ostium was 9.70 mm2 and that of the right was 6.99 mm2 . The left coronary ostium was significantly larger in size than the right with a p-value < 0.05 when their means were compared using the t-test. Conclusion: The majority of coronary ostia were located in their respective aortic sinuses below the sinutubular junction. Knowledge of the location of coronary ostia in the ascending aorta is important during angiography and surgery around the aortic root.

First North American experience with the transfemoral ACURATE-neoTM self-expanding transcatheter aortic bioprosthesis.

Transcatheter aortic valve implantation (TAVI) has become a therapeutic alternative for patients presenting with severe symptomatic aortic stenosis and considered at high-surgical risk. Paravalvular leak (PVL), conduction disorders, and coronary obstruction remain unresolved procedure-related complications. The aim of this manuscript was to report the first North American experience with the ACURATE-neoTM aortic bioprosthesis and its ACURATE-TFTM delivery system (Symetis S.A., Ecublens, Switzerland). Transfemoral ACURATE-neoTM aortic valve implantation was performed in 20 patients. Clinical and echocardiographic assessment was performed at baseline, postprocedure and at least 30 days. Outcomes were assessed according to valvular academic research consortium (VARC-2) criteria. The mean age was 82.7 ± 7.0 years with a mean logistic-EuroSCORE-II of 5.0 ± 2.9% and Society of Thoracic Surgeons score of 4.7 ± 2.3%. Device success was achieved in all patients. The mean distance between the aortic-annulus and the left main coronary artery ostium was 14.3 ± 3.2 mm, and eight (40%) patients had <12 mm. At 30 days, there were no deaths, conversions to surgery, or major procedure-related complications. New-pacemaker implantation was required in one (5.3%) patient. ACURATE-neoTM implantation resulted in a significant reduction in mean transvalvular gradient (49.9 ± 15.8 to 9.7 ± 5.7 mm Hg, P < 0.0001) and increase in effective-orifice area (0.65 ± 0.16 to 1.83 ± 0.36 cm2 , P = 0.001) at hospital discharge. Paravalvular leak was absent in four (20%) patients, trace in nine (45%) patients, and mild in seven (35%) patients. Hospital discharge occurred at a mean of 7.0 ± 4.5 days, and all patients were in NYHA class I-II at a mean follow-up of 8.6 ± 2.3 months. The present initial North American experience shows that the ACURATE-neoTM aortic bioprosthesis was safely and successfully implanted by transfemoral approach. The special design of this newer-generation device affords a stable and predictable implantation, while providing optimal hemodynamic performance with a relatively low rate of PPI. © 2016 Wiley Periodicals, Inc.

Septal fluttering- an important echocardiographic diagnostic sign of anomalous origin of left coronary artery from pulmonary trunk (ALCAPA)

A 49-year old woman presented with exertional dyspnoea NYHA class-II for last three year, with recent worsening in the past six months. Transrthoracic echocardiography (TTE) revealed dilated left ventricle and atrium with systolic dysfunction (EF=35%). Apical 4-chamber view showed continous low flow signals (diastolic more than systolic) in the interventricular septum detected by continous Doppler interrogation (Fig.1, 2). Beside mild mitral regurgitation, and dilated ostium of right coronary artery (RCA), other abnormalities could not be detected. Coronary angiogram showed absent left coronary ostium in aortic sinus, dilated and tortuous right coronary artery (RCA) giving abundant intercoronary anastomoses to left coronary artery (LCA) which was later opacifying the main pulmonary artery in the delayed filling phase thus establishing diagnosis of ALCAPA (Fig. 3). The left coronary ostium arising from the pulmonary trunk, a sign qua non could not be seen on TTE because of poor parasternal short-axis echo window. ALCAPA is a rare congenital coronary anomaly with an incidence of 1 in 300,000 live births [1-3]. Angiography whether invasive or computed is its important modalities. However, they carry the disadvantage of radiation, contrast exposure, cost, and nephrotoxity. On the other hand, transrthoracic echocardiography (TTE) is an important non-invasive reliable modality which helps in its diagnosis as it gives important information regarding the anatomic, functional, and hemodynamic evaluation. Abundant intercoronary septal collaterals with continuous flow, particularly in mid-systole and more in diastole were imparting septal fluttering indicating ALCAPA which was subsequently confirmed on angiogram. Such low flow signals differentiate it from the small muscular ventricular septal defects which shunt in systole and RCA to pulmonary artery fistula where connections are epicardial and will have different angiographic appearances. Although LCA originating from the pulmonary artery in parasternal short-axis view is most diagnostic, it may not always be appreciated because of poor widow, and LCA remaining close to the aorta, and therefore septal fluttering in another pointer towards its diagnostic [4]. It suggests left-to-right shunting from RCA via LCA to main pulmonary artery through intercoronary septal collaterals, and low pulmonary vascular resistance which is in the opposite direction of normal LCA and is prominent in the diastolic phase. Adult survivors of ALCAPA are often incapacitated by myocardial ischemia, arrhythmias and cardiomyopathy. Survival without surgery (direct transfer of LCA from pulmonary artery, bypass or Takeuchi repair) is exceedingly rare beyond fourth or fifth decade as low pulmonary artery pressure results in coronary steal phenomenon [5]. Some may remain asymptomatic until adulthood due to superdominant RCA, become symptomatic due to fixed myocardial ischemia and coronary steal phenomenon [6]. The more collateral channels exist between RCA and anomalous left coronary system (ALCA), the longer the patient may survive.

Double Non Coronary Aortic Sinuses: An Autopsy Case Finding Showing the Arterial Variation

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.

Reaching an Unreachable Left Main Coronary Ostium in a Patient with Dilated Aortic Root

This case report describes the use of an extended guiding system with an anchoring coronary guidewire to facilitate diagnostic coronary angiography and subsequent coronary stent delivery in a patient with severe aortic regurgitation and dilated aortic root.

Diagnostic Value of Transthoracic Echocardiography in Patients With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary abnormality associated with early infant mortality and sudden death in adults. Transthoracic echocardiography (TTE) plays an important role in early detection and diagnosis of ALCAPA as a noninvasive modality. However, its diagnostic value is not well studied. The purpose of this study is to determine the performance of TTE in the diagnostic assessment of ALCAPA as compared with coronary CT and invasive coronary angiography.A total of 22 patients (13 women and 9 men, mean age, 12.9 ± 19.5 years) with ALCAPA who underwent echocardiographic examination for clinical diagnosis were retrospectively reviewed and analyzed. Transthoracic echocardiographic features of ALCAPA were analyzed and its diagnostic value was compared with invasive coronary angiography and coronary CT angiography (CTA) with surgical findings serving as the gold standard. Surgery was performed in all of the patients to establish the dual coronary artery system. Five underwent the Takeuchi procedure and 17 had re-implantation of the anomalous left coronary artery. Of 20 patients, echocardiographic diagnoses were in good agreement with findings at surgery, resulting in the diagnostic accuracy of 90.9%. Two cases were misdiagnosed—one as the right coronary artery to pulmonary artery fistula and the other as rheumatic heart disease. The echocardiographic features of these patients with ALCAPA included: abnormal left coronary ostium arising from the pulmonary trunk with retrograde coronary artery flow in 20 patients; enlargement of the right coronary artery in 17 patients; abundant intercoronary septal collaterals in 17 patients; and moderate and significant mitral regurgitation in 14 patients. The diagnostic accuracy of invasive coronary angiography (in 17 patients) and coronary CTA (in 9 patients) was 100%.This study shows that TTE is an accurate, noninvasive imaging modality for displaying the origin of coronary arteries and demonstrating the coronary courses as well as other associated abnormalities in patients with ALCAPA.

Quadricuspid Aortic Valve: Characteristics, Associated Structural Cardiovascular Abnormalities, and Clinical Outcomes.

Quadricuspid aortic valve (QAV) is a rare congenital cardiac defect. This study sought to determine QAV frequency in a large echocardiography database, to characterize associated cardiovascular abnormalities, and to describe long-term outcomes. Fifty patients (mean ± SD age, 43.5 ± 21.8 years at the time of the index diagnosis; female sex, 52%) received a diagnosis of QAV between January 1, 1975, and March 14, 2014 (frequency, 0.006%). The QAV was type A in 32% and type B in 32% (Hurwitz and Roberts classification). Aortic dilatation was present in 29% of the patients, and 26% had moderate or severe aortic valve regurgitation at the index diagnosis. Stenosis affected only 8% of the valves and was mild. Other findings, including abnormalities of other cardiac valves, septal defects, persistent left superior vena cava, and patent ductus arteriosus, were present in 32% of patients. During a mean ± SD follow-up of 4.8 ± 5.6 years, 8 patients underwent aortic valve surgery, with severe aortic valve regurgitation being the surgical indication in 7 patients. One patient with mild to moderate aortic valve regurgitation underwent aortic valve repair for obstruction of the left coronary ostium by the accessory cusp of QAV. No infective endocarditis or aortic dissection was found. Overall survival was 91.5% and 87.7% at 5 and 10 years. Aortic dilatation and other structural cardiac abnormalities were relatively common among patients with QAV. Aortic valve regurgitation was the predominant hemodynamic abnormality and the indication for aortic valve surgery in most patients who received surgery. Long-term survival was excellent.

Aortic insufficiency in a patient with a quadricuspid aortic valve and abnormal left coronary ostium

A 64-year-old female had symptomatic severe aortic insufficiency and was taken up for aortic valve replacement. The patient was found to have a quadricuspid aortic valve and abnormally located early bifurcated left coronary ostium which were very near to the commissures. There is a risk of damaging the coronary ostia while excising the valve or the prosthetic valve can obstruct the abnormally located ostia. Intraoperative transesophageal echocardiography can help in making an accurate intraoperative diagnosis and deciding aortotomy incision and valve excision. This patient underwent successful aortic valve replacement taking great care to save the abnormally located left coronary ostium.

Surgical Unroofing for Anomalous Aortic Origin of Coronary Arteries

Anomalous aortic origin of a coronary artery (AAOCA) from an opposite sinus of Valsalva is an uncommon congenital defect that is typically only discovered on cardiac catheterization or on autopsy following sudden cardiac death. Conjectured mechanisms for the ischemia are generally believed to relate to the unique and easily obstructed geometry of the coronary ostium and the stenotic intramural coronary segment. Given the potentially devastating consequences of not repairing an AAOCA—that is, sudden cardiac death—these patients should undergo repair of the anomaly when it is discovered. Multiple options for surgically correcting the AAOCA have been developed, and the most used approaches include coronary artery bypass grafting, coronary reimplantation, and unroofing of the intramural segment. Here we present the technique for surgical unroofing of the intramural segment of an anomalous coronary artery of aortic origin.

Automatic aortic root landmark detection in CTA images for preprocedural planning of transcatheter aortic valve implantation.

Transcatheter aortic valve implantation is currently a well-established minimal invasive treatment option for patients with severe aortic valve stenosis. CT Angiography is used for the pre-operative planning and sizing of the prosthesis. To reduce the inconsistency in sizing due to interobserver variability, we introduce and evaluate an automatic aortic root landmarks detection method to determine the sizing parameters. The proposed algorithm detects the sinotubular junction, two coronary ostia, and three valvular hinge points on a segmented aortic root surface. Using these aortic root landmarks, the automated method determines annulus radius, annulus orientation, and distance from annulus plane to right and left coronary ostia. Validation is performed by the comparison with manual measurements of two observers for 40 CTA image datasets. Detection of landmarks showed high accuracy where the mean distance between the automatically detected and reference landmarks was 2.81 ± 2.08 mm, comparable to the interobserver variation of 2.67 ± 2.52 mm. The mean annulus to coronary ostium distance was 16.9 ± 3.3 and 17.1 ± 3.3 mm for the automated and the reference manual measurements, respectively, with a mean paired difference of 1.89 ± 1.71 mm and interobserver mean paired difference of 1.38 ± 1.52 mm. Automated detection of aortic root landmarks enables automated sizing with good agreement with manual measurements, which suggests applicability of the presented method in current clinical practice.

Morphological characterisation of the coronary arteries in African sheep (Ovis orientalis). Differential analysis with those of humans and other animal species.

Despite the importance of the coronary system in the African sheep as a possible experimental model, there is little information about this particular vascular system. The objective of this investigation was to characterise morpho- logically the coronary arteries and their branches in African sheep. This descriptive cross-sectional study evaluated the coronary arteries and their branches of 62 hearts of short hair sheep. The right and left coronary ostia were perfused with a semi-synthetic resin (Palatal GP40L 85%; styrene 15%) dyed with mineral red. The morphological characteristics were evaluated using a digital calibrator and the biometrics of the coronary arteries and their branches were registered. The right coronary artery had a proximal calibre of 2.11 ± 0.46 mm. The subsinusal interventricular branch ended at the middle third of the homonym sulcus in 19 (30.6%) specimens. The left coronary artery had a diameter of 5.38 ± ± 1.59 mm and a length of 4.67 ± 3.32 mm. This artery bifurcated itself in the paraconal interventricular branch and the left circumflex branch in 57 (91.9%) hearts and trifurcated with an additional left diagonal branch in 5 (8.1%) spec- imens. Left coronary artery dominance was observed in 51 (82.3%) specimens, whereas in 11 (17.7%) cases the coronary circulation dominance was balanced. Due to the similitude in the features of the coronary arteries between African sheep and humans, this animal model can be proposed for procedural and haemodynamic activities.

Morphometry and topography of the coronary ostia in the European bison.

Coronary vessels have been widely studied in many species of domestic and wild mammals. However, there are no available literature reports describing the morphology and morphometry of the coronary ostia of the European bison (Bison bonasus). The aim of this study was to measure the area of the coronary ostia and assess their localisation in the coronary sinuses of the aortic root in the European bison. The study material comprised 27 hearts from European bison of both sexes (16 males and 11 females), from 3 months to 26 years old, inhabiting the Bialowieza Forest (Bialowieza National Park, Poland). The animals were divided into two age groups: ≤ 5 years (group I) and > 5 years (group II). In all the studied European bison, the aortic valve consisted of three semilunar leaflets, left, right and septal. The ostia of both coronary arteries were located beneath the sinotubular junction. The dimensions of the left coronary ostium were larger than those of the right coronary ostium. They were longer by on average 4.5 mm (95% confidence interval [CI] 3.5-5.6 mm), they were wider by on average 1.6 mm (95% CI 1.0-2.2 mm) and they had a larger area by on average 31.6 mm2 (95% CI 22.7-40.5 mm2). This was evident both in young and in adult bison. After adjusting for age, there were no differences in the ostia dimensions between males and females. There were no differences in the structure of the left and right coronary arteries in nine animals. In the remaining 18 animals, there were variations in the morphology of the coronary ostia or additional ostia. Because of the anatomical similarity between the European bison and other ruminants, the results of this study can be applied to the other species including endangered ones.

Acute coronary obstruction following transcatheter aortic valve implantation: Small vessels, big problems

Transcatheter aortic valve implantation (TAVI) has become in this last decade an alternative treatment to surgery in patients with severe symptomatic aortic stenosis (AS), with a high or prohibitive surgical risk [1]. Despite advances in the development of new devices and the growing experience of centers performing the procedure, the implant is not exempt of risks. Among the potential complications, acute coronary obstruction (CO) represents a rare complication (b1%), but with a high morbidity and mortality [2]. In the majority of the reported cases, the main mechanism of the obstruction is a displacement of the calcified native valve leaflets over the main coronary ostia. The left coronary artery ostium is more frequently affected (~88%) due to its anatomical arrangement [2–3]. Given the significant quantity of ischemic myocardium caused by a left main occlusion, the clinical manifestations are substantial, presented as maintained severe arterial hypotension, electrocardiographic changes (mainly alterations of the ST segment) and/or malignant ventricular arrhythmias [2–4]. However, we are reporting two cases of acute CO following TAVI that, despite occurring

Pathologie du médiastin. Cas no 2. Lymphome B inclassable, avec des caractéristiques intermédiaires entre un lymphome de Hodgkin classique et un lymphome B à grandes cellules primitif du médiastin

We present a unique case of sudden death in a 21-year-old man with history of cocaine use and a solitary fibromuscular dysplastic lesion completely occluding the left coronary artery ostium. We document intimal proliferation of myofibroblasts at the opening of the left coronary ostium without other concomitant lesions. This report discusses the gross and histologic features of the lesion, explores in careful detail the possible etiologies, and gives a comprehensive literature review of isolated coronary ostial fibromuscular dysplasia presenting with sudden death.

Neo-Ostium Creation for Anomalous Aortic Origin of the Coronary Artery

For the anomalous aortic origin of the coronary artery with interarterial course, surgical repair is recommended. We describe a technique of neo-ostium creation at the correct anatomic position for the right coronary artery arising from a single left coronary ostium without an intramural course and coursing between the ascending aorta and the main pulmonary artery.

Abstract 48: Small Arteritis is the Basic Pathology of Kawasaki Disease

Introduction: Pathologic processes of two features in Kawasaki disease (KD) have not been elucidated. The one is the preponderance of aneurysms in the main coronary artery. The other is the discontinuity in the process of the vasculitis between those of microvessels and small arteries, and those of medium-sized to large arteries. Hypothesis: We assessed the hypothesis that arteritis of the vasa vasorum, which we described for the first time, plays a key role in the preponderance of aneurysms in the main coronary artery in KD. Methods: We examined the relationship between patient age at onset of KD and the distance ratio of the aneurysm in the left main coronary artery (LMCA) to clarify the role of arteritis of the coronary vasa vasorum, originated from the atrial and ventricular branches of the peripheral coronary artery, in the ischemia at the media of LMCA. The distance ratio Y was defined as D1/D2 х 100, where D1 and D2 are the distances from the left coronary ostium to the proximal point of the aneurysm and to the bifurcation into the left anterior descending and left circumflex artery, respectively. We then studied the relations between cardiogenic shock and extracardiac aneurysm, and coronary aneurysm in our cases and those of literatures. Results: The mean distance ratio of 56 aneurysms correlated with age, similar to the development of the coronary vasa vasorum: Y = 49.75383 - 3.3739X, P = 0.002987, R = 0.356. Cardiogenic shock which indicates severe interstitial myocarditis and severe arteritis of the coronary vasa vasorum occurs in the 1st week of the illness and is followed by aneurysm formation in LMCA. Extracardiac aneurysm due to severe arteritis of its vasa vasorum associates with severe arteritis of the coronary vasa vasorum originated from the aorta which may induce dilatation at the proximal portion of LMCA. Thus, aneurysm in LMCA complicated with extracardiac aneurysm reveals its proximal extension. In conclusion, these findings may contribute to understand morphogenesis and to investigate the treatment on KD.

Aortic annulus and root characteristics in severe aortic stenosis due to bicuspid aortic valve and tricuspid aortic valves: implications for transcatheter aortic valve therapies.

Patients with severe aortic stenosis due to BAV are excluded from transcatheter aortic valve replacement (TAVR) due to concern for asymmetric expansion and valve dysfunction. We sought to characterize the aortic root and annulus in bicuspid aortic valve (BAV) and tricuspid aortic valves (TAV). We identified patients with severe AS who underwent multi-detector computed tomographic (MDCT) imaging prior to surgical aortic valve replacement (SAVR, n = 200) for BAV and TAVR (n = 200) for TAV from 2010 to 2013. The presence of a BAV was confirmed on surgical and pathological review. Annulus measurements of the basal ring (short- and long-axis, area-derived diameter), coronary ostia height, sinus area (SA), sino-tubular junction area (STJ), calcification and eccentricity index (EI, 1-short axis/long axis) were made. Patients with TAV were older (78.8 years vs. 57.8 years, P = 0.04) than those with BAV. The aortic annulus area (5.21 ± 2.1 cm(2) vs. 4.63 ± 2.0 cm(2) , P = 0.0001), sinus of Valsalva diameter (3.7 ± 0.9 cm vs. 3.1 ± 0.1 cm, P = 0.001) and ascending aorta diameter (3.5 ± 0.7 cm vs. 2.97 ± 0.6 cm, P = 0.001) were significantly larger with BAV. Bicuspid aortic annuli were significantly less elliptical (EI, 1.24 ± 0.1 vs. 1.29 ± 0.1, P = 0.006) and more circular (39% vs. 4%, P < 0.001) compared to the TAV annulus. There was more eccentric annular calcification in BAV vs. TAV (68% vs. 32%, P < 0.001). The mean distance from the aortic annulus to the left main coronary ostium was less than the right coronary ostium. Less than 10% of the BAV annuli would not fit a currently available valved stents. Bicuspid aortic valves have a larger annulus size, sinus of Valsalva and ascending aorta dimensions. In addition, the BAV aortic annuli appear circular and most will fit currently available commercial valved stents.