Ventriculo-aortic Junction Research Articles

Anthropo-morphometric patterns of design and proportionality of the aortic valve leaflets in light of reconstructive surgery

Background. As long as the design of leaflets is crucial for aortic valve replacement, inaccurate reconstruction can result in failure or stenosis postoperatively.Aim. To analyze average parameters of normal valve leaflets and to assess the correlation between various parameters of a normal aortic valve and personal morphometrics. Methods. The morphometrics of the aortic root were assessed on 54 specimens of the adult heart without any valvular abnormality. We measured following parameters: circumference of the ventriculo-aortic junction and the sino-tubular junction; inter-commissural distance, length of free margin, length of cusp attachment, and height for right coronary, non-coronary, and left coronary aortic leaflets. Results. Based on the average values, the left coronary leaflet is distinguished by the smallest dimensions of the length of free margin and length of cusp attachment. The height of the left coronary leaflet is maximum as compared to the right coronary and non-coronary leaflets, but these differences are minimal (up to 0.2 mm), where the left coronary leaflet is the smallest. Statistically, no significant intergroup difference was found. For all valve sizes, p > 0.05 (inter-commissural distance p = 0.083, length of free margin p = 0.331, length of cusp attachment p = 0.056, height of leaflet p = 0.518). Significant correlations were found between all aortic valve leaflet sizes and the ventriculo-aortic junction and the sino-tubular junction. A weaker correlation was found between all leaflets sizes and the body height.Conclusion. The findings can be used to optimize the leaflet reconstruction and improve the aortic valve function. Received 9 September 2020. Revised 10 September 2021. Accepted 29 June 2022. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authorsConception and study design: R.N. Komarov, V.N. Nikolenko, S.N. OdinokovaData collection and analysis: S.N. Odinokova, V.V. Studennikova, L.O. SeverginaStatistical analysis: S.N. OdinokovaDrafting the article: S.N. Odinokova, R.Kh. BelkharoevaCritical revision of the article: R.N. Komarov, V.N. NikolenkoFinal approval of the version to be published: S.N. Odinokova, R.N. Komarov, V.N. Nikolenko, L.O. Severgina, V.V. Studennikova, R.Kh. Belkharoeva

David Procedure: A 21-year Experience With 300 Patients

BackgroundValve-sparing aortic root replacement with the David procedure is an alternative to the Bentall procedure in patients with aortic root aneurysm. The aim of this study was to describe our long-term experience with this technique and the predictive factors of late failure. MethodsBetween January 1998 and August 2019, 300 consecutive patients underwent a David procedure. Clinical and echocardiographic early- and long-term outcomes were analyzed. Median follow-up was 7.0 years (range, 4.1-11.5), with 98.3% complete. ResultsEarly mortality was 1%. No early valve-related reoperations occurred. There were 9 cardiac-related deaths and 22 reinterventions (19 valve-related). All patients survived reoperation. In 3 patients reintervention consisted of transcatheter aortic valve implantation. Overall survival rates were 95.3% (95% confidence interval [CI], 92.0-97.2), 91.1% (95% CI, 86.5-94.2), and 82.9% (95% CI, 75.3-88.4) at 5, 10, and 15 years, respectively. Freedom from postoperative aortic insufficiency (AI) grade ≥ 2 was 84.8% (95% CI, 79.9-88.6) and 74.3% (95% CI, 67.4-79.9) at 5 and 10 years, respectively. Freedom from reintervention for aortic valve disease was 97.1% (95% CI, 94.2-98.5), 92.9% (95% CI, 88.2-95.7), and 92.5% (95% CI, 87.1-95.7) at 5, 10, and 15 years, respectively. Preoperative AI ≥ 2 (hazard ratio, 1.782; 95% CI, 1.352-2.350) and a ventriculoaortic junction ≥ 29 mm (hazard ratio, 3.379; 95% CI, 1.726-6.616) were predictive factors for postoperative AI ≥ 2 in a multivariate analysis (P < .001). ConclusionsPreoperative AI ≥ 2 and a ventriculoaortic junction ≥ 29 mm were identified as risk factors for late postoperative AI ≥ 2.

Aortic Valve Repair Using HAART 300 Geometric Annuloplasty Ring: A Review and Echocardiographic Case Series

Aortic valve repair (AVr) aims to preserve the native aortic leaflets and restore normal valve function. In doing so, AVr is a more technically challenging approach than traditional aortic valve replacement. Some of the complexity of repair techniques can be attributed to the unique structure of the functional aortic annulus (FAA), which, unlike the well-defined mitral annulus, is comprised of virtual and functional components. Though stabilizing the ventriculo-aortic junction (VAJ), a component of the FAA, is considered beneficial for patients with chronic aortic insufficiency (AI), the ideal AVr technique remains a subject of much debate. The existing AVr techniques do not completely stabilize the VAJ which may increase susceptibility to recurrent AI due to VAJ dilation. An emerging new technique showing promise for the treatment of both isolated and complex AI is AVr using HAART 300TM geometric annuloplasty ring (GAR). The GAR is implanted below the valve leaflets in the left ventricular outflow tract (LVOT), providing stability and creating a neo-annulus. As with other AVr subtypes, this procedure has a learning curve. There are unique surgical and echocardiographic aspects of AVr with GAR, including the appearance of the LVOT, the aortic valve leaflets, and their motion which cardiac anesthesiologists and echocardiographers must be familiar with. In this work, using an eight-patient echocardiographic case series, we provide an overview of this novel AVr technique, including some unique aspects of device sizing, patient selection, expected post-repair echocardiographic features, and a review of outcomes data.

A simplified approach to determine the ventriculoaortic junction diameter in the reimplantation procedures.

In aortic valve–sparing procedures, sufficient effective height (EH) is essential for long-term aortic valve durability.1 The plication of the nodule of Arantius (central plication) and the free margin resuspension with polytetrafluoroethylene sutures are performed to obtain sufficient EH, but overcorrection brings the immobility of the cusp and the gap in the central coaptation zone. In the reimplantation procedure, reducing the ventriculoaortic junction (VAJ) diameter with the proximal suture line is another option for increasing the coaptation height2; however, the degree of the reduction must be decided at the beginning of the procedure before the cusp configuration is completed.

Pulmonary Autograft Sinus Muscular Inclusion: A Relative Contraindication for Ross Procedure

Muscular inclusion at the base of the right coronary sinus in aortic valves has previously been described by our group. It occurs due to crossing of the ventriculoaortic junction above the level of the virtual basal ring and aortic cusp insertion.1 This anatomic entity, however, has not been previously described in pulmonary valves. Herein, we are demonstrating that muscular inclusion at the base of the pulmonary valve sinus can also occur (Figure 1; blue arrows depict anterior pulmonary valve cusp; black arrows depict muscular inclusion of the anterior pulmonary valve sinus), but it is a subtle finding, and can hence be easily overlooked.

Geometry and flow in ascending aortic aneurysms are influenced by left ventricular outflow tract orientation: Detecting increased wall shear stress on the outer curve of proximal aortic aneurysms

BackgroundThe geometrical characterization of ascending thoracic aortic aneurysms in clinical practice is limited to diameter measurements. Despite growing interest in hemodynamic assessment, its relationship with ascending thoracic aortic aneurysm pathogenesis is poorly understood. This study examines the relationship between geometry of the ventriculo-aortic junction and blood flow patterns in ascending thoracic aortic aneurysm disease. MethodsThirty-three patients with ascending thoracic aortic aneurysms (exclusions: bicuspid aortic valves, connective tissue disease) underwent 4-dimensional flow magnetic resonance imaging. After image segmentation, geometrical parameters were measured, including aortic curvature, tortuosity, length, and diameter. A unique angular measurement made by the trajectory of the left ventricular outflow tract axis and the proximal aorta was also conducted. Velocity profiles were quantitatively and qualitatively analyzed. In addition, 11 patients (33%) underwent wall shear stress mapping of the ascending thoracic aortic aneurysm region using computational fluid dynamics simulation. ResultsGreater left ventricular outflow tract aortic angles were associated with larger aortic diameters at the levels of the sinus (coefficient = 0.387, P = .014) and ascending aorta (coefficient = 0.284, P = .031). Patients with left ventricular outflow tract aortic angles greater than 60° had marked asymmetric flow acceleration on the outer curvature in the proximal aorta, ascertained from 4-dimensional flow analysis. For patients undergoing computational fluid dynamics assessment, regression analysis found that higher left ventricular outflow tract aortic angles were associated with significantly higher wall shear stress values in the outer curve of the aorta (coefficient 0.07, 95% confidence interval 0.04-0.11, P = .002): Angles greater than 50° yielded time-averaged wall shear stress values greater than 2.5 Pa, exhibiting a linear relationship. ConclusionsOur findings strengthen the hypothesis of flow-mediated ascending thoracic aortic aneurysm disease progression and that left ventricular outflow tract aortic angle may be a predictor of disease severity.

Dynamic Volumetric Assessment of the Aortic Root: The Influence of Bicuspid Aortic Valve Competence

Aortic root evaluation is conventionally based on 2-dimensional measurements at a single phase of the cardiac cycle. This work presents an image analysis method for assessing dynamic 3-dimensional changes in the aortic root of minimally calcified bicuspid aortic valves (BAVs) with and without moderate to severe aortic regurgitation. The aortic root was segmented over the full cardiac cycle in 3-dimensional transesophageal echocardiographic images acquired from 19 patients with minimally calcified BAVs and from 16 patients with physiologically normal tricuspid aortic valves (TAVs). The size and dynamics of the aortic root were assessed using the following image-derived measurements: absolute mean root volume and mean area at the level of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction, as well as normalized root volume change and normalized area change of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction over the cardiac cycle. Normalized volume change over the cardiac cycle was significantly greater in BAV roots with moderate to severe regurgitation than in normal TAV roots and in BAV roots with no or mild regurgitation. Aortic root dynamics were most significantly different at the mid-level of the sinuses of Valsalva in BAVs with moderate to severe regurgitation than in competent TAVs and BAVs. Echocardiographic reconstruction of the aortic root demonstrates significant differences in dynamics of BAV roots with moderate to severe regurgitation relative to physiologically normal TAVs and competent BAVs. This finding may have implications for risk of future dilatation, dissection, or rupture, which warrant further investigation.

Early evaluation of the aortic root after Nicks' procedure

Objective(s)To determine the influence of surgical techniques adopted to avoid suture line disruption, periprosthetic leakage, patch dislodgement, pericardial patch aneurysm formation, and the long-term stability of aortic root enlargement (ARE) during aortic valve replacement (AVR).MethodsOne hundred fifteen patients undergoing AVR or combined aortic and mitral valve replacements with Nicks' posterior ARE between 1997 and 2019 underwent long-term echocardiographic and angio-computed tomographic evaluation. Age was 11-72 years (AVR: median, 30; interquartile range, 21-47 years; AVR and mitral valve replacement: median, 27.5; interquartile range, 20-37.5 years). The aortotomy was closed using autologous pericardial patch and Teflon-buttressed sutures.ResultsHospital mortality was 1.7% (n = 2), with 4 (3.5%) late deaths. At a mean follow-up of 123.11 ± 77.67 months, the survival probability from Kaplan–Meier was 93.25 ± 0.03%. No cases of severe prosthesis–patient mismatch (PPM) were observed, and only 2 patients had moderate PPM. Median aortic root diameters at the level of sinus of Valsalva and sinotubular junction were 32 (29-35) mm and 33 (30-36) mm, respectively, at discharge, and were 33 (30-36) mm, and 33 (31-37) mm, respectively, at latest follow-up, with no cases of late pericardial patch aneurysm.ConclusionsARE is a safe adjunct to AVR in patients with a small aortic annulus to prevent PPM. Retention of a pericardial collar and Teflon-buttressed sutures is an expedient, safe, and effective technique in reducing bleeding at the enlarged ventriculo-aortic junction. Autologous pericardial patch aortoplasty is not associated with late aneurysm/pseudoaneurysm formation.

Reimplantation for annular stabilization in bicuspid aortic valve repair.

To review the outcomes of bicuspid aortic valve repair with the reimplantation technique. From 2006 to 2018, 46 patients with bicuspid aortic valve underwent the reimplantation procedure for aortic valve repair. Those patients were included in this study. The mean age was 45 ± 15years and 44 were male. Preoperative echocardiography showed a mean ventriculoaortic junction diameter of 28 ± 3mm. The mean diameter at the sinus of Valsalva was 41 ± 9mm. The minimum cusp height was 19 ± 3mm. Regarding cusp repair technique, central plication was used in 45 patients, free margin reinforcement in 10 patients, and patch repair in 4 patients. Follow-up was performed by annual echocardiography. There were no hospital deaths. All patients were found with either no/trivial or mild AR on postoperative transesophageal echocardiography. The postoperative ventriculoaortic junction diameter was 23 ± 2mm and 83 ± 17% preoperatively. Freedom from moderate AR was 85 ± 6% at 5years, and freedom from reoperation was 93 ± 4% at 5years. Reimplantation for bicuspid aortic valve repair showed acceptable mid-term outcomes.

Continuous-Flow Left Ventricular Assist Devices and the Aortic Valve: Interactions, Issues, and Surgical Therapy.

Concomitant valve disease is common in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) implantation. In this review, we characterize the epidemiology and management of aortic valve disease following CF-LVAD. Studies suggest that 20-40% of patients have mild or greater aortic insufficiency (AI) at baseline and that AI progresses following CF-LVAD implantation. AI, either pre-existing or de novo, can have deleterious effects on LVAD efficacy and clinical outcomes. Surgical methods to correct AI in patients supported with CF-LVAD include central oversewing of the aortic valve, complete closure of the aortic valve, patch closure of the ventriculo-aortic junction, or aortic valve replacement with a bioprosthesis. Transcatheter options have recently emerged as feasible modalities to address AI. CF-LVADs contribute to the progression of aortic insufficiency (AI) and its development de novo. Prompt recognition, assessment, and treatment are important. Aortic valve repairs and replacements, now including TAVR, are the primary surgical methods to correct AI.

Periaortic ventricular tachycardia in structural heart disease: Evidence of localized reentrant mechanisms

The mechanisms for scar-related ventricular tachycardia (VT) originating from the periaortic region remain incompletely characterized. The purpose of this study was to map the circuits responsible for periaortic VT in high resolution. Cases with periaortic VT (2016-2020) were analyzed to characterize the substrate and mechanisms with multielectrode mapping. Periaortic VT was defined as low-voltage and/or deceleration zones within 2 cm of the left ventriculoaortic junction with a corresponding critical site during VT. Forty-nine periaortic monomorphic VTs were analyzed in 30 patients (25% of all patients with nonischemic cardiomyopathy). Isolated periaortic substrate was observed in 27% of patients, with 73% having concomitant scar, most commonly in the mid-septum (47%). Deceleration zones were equally prevalent on the septal and lateral portions of the periaortic region (87% vs 73%; P = .19). During activation mapping of VT (tachycardia cycle length 392 ± 105 ms), localized reentrant patterns of activation (14 mm [10-17 mm] × 10 mm [7-14 mm]) were demonstrated in 63% and 37% of VTs showed centrifugal activation, consistent with a focal breakout pattern. Ninety-three percent of VTs fulfilled criteria for a reentrant mechanism. Sixty-five percent of reentrant circuits had endocardial activation gaps within the tachycardia cycle length (3-dimensional circuitry), which were associated with higher rates of recurrence as compared with 2-dimensional complete circuits at 1 year (73% vs 37%; P = .028). Periaortic VTs were observed in 25% of patients with nonischemic cardiomyopathy and scar-related VT. For the first time, localized reentry confined to this anatomically challenging region was demonstrated as the predominant mechanism by high-resolution circuit activation mapping.

External suture annuloplasty for mild to moderate and moderate aortic regurgitation due to an isolated type Ic lesion.

Whether mild to moderate and moderate aortic regurgitation should be corrected surgically during other cardiovascular surgeries remains controversial. We evaluated the effectiveness of external suture annuloplasty in such cases. Among 95 patients undergoing aortic valve repair between December 2013 and March 2018, five patients with mild to moderate and moderate aortic regurgitation due to aortic annulus dilatation (type Ic lesion) underwent surgery for mitral regurgitation and/or thoracic aortic aneurysm. Aortic valves were repaired with external suture annuloplasty alone with a mean Hegar dilator size of 20.4 ± 0.8 (20.0-22.0)mm at the same time and were followed up echocardiographically. There were no cases of mortality or major morbidity. Intraoperative direct measurement revealed ventriculoaortic junction size of 25.0 ± 0.8 (24.0-27.0)mm. The average cardiopulmonary bypass time and aortic cross-clamping time were 139 ± 46 (76-205)min and 105 ± 38 (58-172)min, respectively. Postoperative transthoracic echocardiogram during hospitalization showed trivial aortic regurgitation in all cases, with average ventriculoaortic junction size, aortic valve area, and peak and mean transvalvular gradient of 19.1 ± 0.7 (18.0-20.3)mm, 2.24 ± 0.48 (1.60-3.00)cm2, 6.4 ± 1.9 (4.0-9.2)mmHg, and 3.5 ± 1.1 (2.1-5.2)mmHg, respectively. Ventriculoaortic junction size was significantly decreased (P < 0.05). There have been no changes in ventriculoaortic junction size (P = 0.32) or other echocardiographic findings for 24 ± 6 (17-36)months after surgery. Although concomitant with other cardiac surgeries, mild to moderate and moderate aortic regurgitation could be repaired without clinically relevant additional surgical duration. External suture annuloplasty is a useful, safe, and secure treatment choice for type Ic lesion-induced aortic regurgitation.

Natural history of the aortic wall changes in adults with the degenerative tricuspid aortic valve stenosis: The morphometric proofs and implications for echocardiography

Background/Aim. So far, no study has been focused exclusively on the tricuspid aortic valve stenosis (TAV) in the aorta without severe dilatation and none has aimed at correlating the high mycroscopy findings with the echocardiographic parameters. This research was conducted on the postulate that detecting the histopathological changes of different severity in the aortic wall could tailor decision about an aortic surgery. The aim of this study was to grade the histopathological changes in the wall of the nonseverely dilated ascending aorta in patients with the severe, calcific TAV stenosis and to correlate them with the echocardiographic parameters in order to analyze when the ascending aorta should be replaced simultaneously with the aortic valve replacement (AVR). Methods. The samples from 37 patients subjected to the AVR and the samples from the control group were analyzed morphologically. The echocardiographic parameters obtained in the TAV stenosis patients were preoperatively correlated with the morphological data, age and gender, diameters of the ventriculo-aortic junction (AA), the sinus Valsalvae (SV) and sinotubular junction (STJ), the largest diameter of the visualized ascending aorta (AscA), the sinus Valsalvae index (SVI) and AscA/AA index. Results. We confirmed morphometrically the exact region of the hemodynamic stress influence with the mathematical distinction in comparison to the controls. In this region, the gradual elastic lamellae disruption was proved by a statistically significant difference through the 3 grades. The elastic skeleton alterations were potentiated with aging and in females. The morphometric parameters of the ascending aorta wall statistically significantly correlated with the echocardiographic parameters: AA, SV, AscA and SVI. The echocardiographic parameters tended to be higher in the most severe grade 3, in the patients younger than 65 years of age. The AscAof more than 4.5 cm was associated with the irreversible morphological defects in these patients. Conclusion. The hemodynamic stress induced by the TAV stenosis leads to the ascending aorta elastic lamellae disruption that could be histopathologically graded and correlated with the echocardiographic parameters of the ascending aorta providing a potential tool for decision-making process in cases when the ascending aorta replacement is considered simultaneously with the AVR.

The evaluation of the aortic annulus displacement during cardiac cycle using magnetic resonance imaging

BackgroundThe stress in the ascending aorta results from many biomechanical factors including the geometry of the vessel and its maximum dimensions, arterial blood pressure and longitudinal systolic stretching due to heart motion. The stretching of the ascending aorta resulting from the longitudinal displacement of the aortic annulus during the heart cycle has not been examined in the general population so far. The aim of the study is to evaluate this parameter using cardiovascular magnetic resonance (CMR) imaging in the general population in all age groups.MethodsThe cardiac magnetic resonance images of 73 patients were evaluated. The maximum distance to which the ventriculo-aortic junction was pulled by the contracting heart (LDAA – longitudinal displacement of the aortic annulus) was measured in the cine coronal sequences. Moreover, the maximum dimensions of the aortic root and the ascending aorta were assessed.ResultsThe LDAA value was on average 11.6 ± 2.9 mm (range: 3-19 mm; 95% CI: 10.9–12.3 mm) and did not differ between males and females (11.8 ± 2.9 mm vs. 11.2 ± 2.9 mm, p = .408). The diameter of the ascending aorta was 32 ± 6.3 mm (range: 20-57 mm). The maximal dimension of the aortic root was 35 ± 5.1 mm (range: 18-42 mm). There was a statistically significant negative correlation between the LDAA and the age of patients (r = −.38, p = .001). There was no significant correlation between the LDAA and aortic root dimension (r = .1, p = .409) and between the LDAA and diameter of the ascending aorta (r = .16, p = .170).ConclusionsHuman aortic root and ascending aorta are significantly stretched during systole and the distance to which the aorta is stretched decreases with age. The measurement of the longitudinal displacement of the aortic annulus using the CMR is feasible and reproducible.

Deep circumferential annuloplasty as an adjunct to repair regurgitant bicuspid aortic valves with a dilated annulus

BackgroundFailure to address the functional aortic annulus during bicuspid aortic valve (BAV) repair has led to early repair failures. The pathology of regurgitant BAV involves annular dilatation, which is more pronounced anteriorly and deep toward the muscular interventricular septum. In this study, we assessed the results of BAV repair using a strategy of deep circumferential annular support involving the septum in patients with a dilated annulus (>26 mm) and moderate to severe aortic regurgitation (AR). MethodsBetween February 1999 and June 2015, 100 patients with regurgitant (≥2+) BAV and a dilated ventriculoaortic junction (VAJ) (≥26 mm) underwent repair with an adjunctive circumferential annuloplasty (reimplantation procedure or ring). External root dissection to accommodate the annuloplasty was carried deep onto the anterior aspect of the interventricular septum. Follow up was complete in 96 patients, with a median follow-up of 31 months and a total of 362 patient-years. Cox regression analysis was used to predict recurrence of AR. ResultsThe mean VAJ diameter was 30 ± 4 mm. Seventy-nine patients exhibited delayed prolapse of the anterior leaflet (conjoined right and left cusps in Siever type 1 or anterior cusp in Siever type 0), and 93 patients underwent reimplantation. In the entire study group, there were no in-hospital deaths, and only 1 patient had 2+ AR on discharge. There was 1 late noncardiac death. At 8 years, freedom from AR ≥2+ was 96.4% and freedom from reoperation was 96.8%. Higher preoperative AR grade, small graft size, and use of a ring were predictive of recurrent AR. ConclusionsRegurgitant BAVs with a dilated annulus display anterior cusp prolapse toward the septum. A deep circumferential annuloplasty may help maintain repair durability.

Correlation of structural defects in the ascending aortic wall to ultrasound parameters: benefits for decision-making process in aortic valve surgery

BackgroundHistopathological changes in the ascending aorta wall in patients with severe tricuspid aortic valve (TAV) stenosis were graded and correlated to echocardiographic parameters. Objective was to associate threshold echocardiographic values with structural defects in the ascending aorta providing a tool to improve decision-making process in cases when simultaneous aortic valve replacement (AVR) and ascending aorta replacement is considered.MethodsBiopsies from 108 TAV stenosis patients subjected to AVR were graded into three grades according to severity of aortic wall changes. Echocardiographic parameters obtained preoperatively and correlated to grade, age, gender and risk factors, were diameters of ventriculo-aortic junction (AA), sinus Valsalva (SV), sinotubular junction (STJ), the largest diameter of the visualized ascending aorta (AscA) as well as indexes: sinus Valsalva (SVI), sinotubular junction (STJI), AscA/AA and STJ/AA.ResultsTwo echocardiographic parameters portrayed grades with statistical significance: STJ (F = 5.417; p = 0.006 (p < 0.05)) and AscA (F = 3.924; p = 0.023 (p < 0.05)). By using multiple predictors in the setting of Regression analysis, statistically significant differences among grades were reached for AA, SV, STJ, AscA and SVI. With further ROC curves analysis, threshold values for different grades were recognized. Grade 2 is identified in patients with AscA > 3.3 cm, while Grade 3 is identified in patients with values of AscA > 3.5 cm, STJ > 2.9 cm and STJI > 1.ConclusionsHemodynamic stress induced by TAV stenosis leads to elastic lamellae disruption in the aortic wall. Those changes could be graded and correlated with echocardiographic parameters of the aortic root and ascending aorta, providing a tool for decision to replace ascending aorta concomitantly with AVR.

THE EFFECT OF VENTRICULO-AORTIC JUNCTION DILATATION ON AORTIC INSUFFICIENCY

The relationship between the Functional Aortic Annulus (FAA), consisting of the Ventriculo-aortic junction (VAJ) and the Sinotubular Junction (STJ) and aortic valve function is incompletely understood. We examined this relationship in a clinically relevant, high fidelity porcine model using a left heart simulator with 3-D echocardiography, hemodynamic assessment, and finite element modeling and by modifying aortic root geometry. Baseline hemodynamic measurements were performed on fresh porcine aortic roots (n=6) on a left heart simulator. VAJ dilatation was performed by remodeling the VAJ and sewing in an oversized Darcon tube graft (diameter=30mm). After dilated VAJ roots were analyzed, the sinotubular junction (STJ) was enlarged by making three veritical incisions at the STJ and patching these areas with three diamond (1cmX1cm) shaped pericardial patches. This created three dependent experimental groups: A) control, B) VAJ dilatation, and C) VAJ + STJ dilatation. Hemodynamic parameters included regurgitant fraction, regurgitant volume, and left ventricular work. 3-D echocardiography measured coaptation surface area. Finite element modeling using (n=10) patient aortic root geometry was performed to determine cusp stresses after each intervention. Baseline VAJ and STJ diameters were 24.3mm interquartile ranges [IQR= 23.3, 24.3] and 24.3mm [IQR=23.3, 25.1]. Following surgical remodeling the VAJ increased to 30mm [IQR=30, 30] and the STJ to 29.8mm [IQR=27.8, 29.8] (p = 0.02). All hemodynamic assessments were similar across groups with the exception of left ventricular work which significantly increased from baseline to VAJ + STJ dilatation (+12%; p=0.03). Regurgitation fraction increased from 4.3% [IQR=3.2, 5.5] at baseline to 14.5% [IQR=13.4, 17.3] (p=0.03) with VAJ dilatation and increased further with STJ dilatation to 18.5% [IQR=10.3, 27.8] (p=0.02). Coaptation surface area decreased from 1.75cm2 [IQR=1.65, 2.00] to 1.23cm2 [IQR=1.05, 1.37] (p=0.02) with VAJ dilatation and further with STJ dilatation to 1.09cm2 [IQR= 1.03, 1.14] (p=0.02 for control and VAJ intervention). An inverse linear relationship was found between VAJ diameter and coaptation surface area (R2=0.70; p=0.001; Figure 1). The combined leaflet stresses in the unaltered root was 530kPa[IQR=380,630] after 4mm diameter VAJ dilatation the stresses increased to 650 kPa [IQR=540,820] (p= 0.001). With an additional 4mm diameter STJ dilatation the leaflet stresses increased to 790 kPa [IQR=600, 1000] (p=0.005). VAJ dilatation produces a graded decrease in leaflet coaptation surface area along with increased leaflet stresses which is further amplified with STJ dilatation. This study provides new insights into mechanisms of annulus mediated AI and their responses to leaflet function and stresses.

Aortic Valve Cusp Coaptation Surface Area Using 3-Dimensional Transesophageal Echocardiography Correlates with Severity of Aortic Valve Insufficiency

The aim of this study was to test both in humans and using finite element (FE) aortic valve (AV) models whether the coaptation surface area (CoapSA) correlates with aortic insufficiency (AI) severity due to dilated aortic roots to determine the validity and utility of 3-dimensional transesophageal echocardiographic-measured CoapSA. Two-pronged, clinical and computational approach. Single university hospital. The study comprised 10 patients with known AI and 98 FE simulations of increasingly dilated human aortic roots. The CoapSA was calculated using intraoperative 3-dimensional transesophageal echocardiography data of patients with isolated AI and compared with established quantifiers of AI. In addition, the CoapSA and effective regurgitant orifice area (EROA) were determined using FE simulations. In the 10 AI patients, regurgitant fraction (RF) increased with EROA (R2 = 0.77, p = 0.0008); CoapSA decreased with RF (R2 = 0.72, p = 0.0020); CoapSA decreased with EROA (R2 = 0.71, p = 0.0021); and normalized CoapSA (CoapSA / [Ventriculo-Aortic Junction × Sinotubular Junction]) decreased with EROA (R2 = 0.60, p = 0.0088). In the 98 FE simulations, normalized CoapSA decreased with EROA (R2 = 0.50, p = 0.0001). In both human and FE AV models, CoapSA was observed to be inversely correlated with AI severity, EROA, and RF, thereby supporting the validity and utility of 3D TEE-measured CoapSA. A clinical implication is the expectation that high values of CoapSA, measured intraoperatively after AV repairs, would correlate with better long-term outcomes of those repairs.

Should the annulus be fixed in aortic valve-sparing root replacement with remodeling?

If the aortic root dilates after native aortic valve-sparing root reconstruction with remodeling, aortic regurgitation may recur. However, it has not been demonstrated clearly that the aortic root dilates after remodeling. This study enrolled 15 patients who underwent an aortic valve-sparing operation with remodeling (2002-2014) but without any ventriculo-aortic junction (VAJ) fixation. Technically, special care was taken to pass the sutures through the fibrous annulus. The diameter of the aortic root (VAJ, neosinus of Valsalva, and sinotubular junction), degree of aortic regurgitation, and effective height of the aortic valve were measured in the patients. All patients had postoperative follow-up, and the median follow-up period was 7.3 (IQR: 3.1-8.3)years. The mean preoperative diameters of the VAJ, sinus of Valsalva, and sinotubular junction were 23.5 ± 2.3 (20-27)mm, 51.1 ± 7.2 (43-60)mm, and 42.4 ± 9.4 (29-58)mm, respectively. The postoperative diameters of the VAJ changed from 21.6 ± 2.6 (early) to 21.8 ± 2.9mm (late) (p = 0.75). The diameters of the sinus of Valsalva and sinotubular junction changed from 26.5 ± 3.0 (early) to 28.5 ± 4.2mm (late) (p = 0.0013), and 22.4 ± 3.0 (early) to 24.3 ± 3.3mm (late) (p = 0.0003), respectively. The effective height of the aortic valve changed from 9.7 ± 1.3 (early) to 8.9 ± 2.0mm (late) (p = 0.08). The degree of aortic regurgitation (grade: 0-4) changed from 0.3 ± 0.5 (early) to 1.2 ± 0.8 (late) (p = 01558). Significant VAJ dilation and changes in aortic valve configuration after our remodeling procedure were not observed. Therefore, fixation of the annulus with remodeling may not be needed for cases without preoperative dilation of the annulus.

Familial intracranial aneurysm, the relationship of the aortic diameter

ObjectivesFamilial predisposition appears as an identified risk factor for cerebrovascular disease. The primary objective of our study was to assess intracranial aneurysm (IA) recurrence rate in a population of familial IA. Secondary objectives were first to analyse the inheritance categorisation/pattern of these families and second to assess the correlation between the aortic diameter on MRI and the aneurysmal characteristics. Patients and methodsOver a period of 20 years (1990–2010), 26 patients from 23 families, identified from a regional register, accepted to participate in this prospective trial in order to determine, the inheritance pattern, the screening of de novo aneurysms by CT angioscan, and the aortic mensuration by MRI. The transmission pattern was categorised into autosomal dominant inheritance, autosomal recessive and autosomal dominance with incomplete penetrance. The aortic diameter was measured: anatomic coverage in the caudo-cranial direction from the iliac arteries to the ventriculo-aortic junction. ResultsAll 26 patients [from 55.4±11.2 years, sex ratio female/male: 1.36] were reviewed after a mean follow-up of 7.9±6.6 years after the diagnosis of a cerebral aneurysm. The characteristics of this population were the diagnostic circumstances such as a subarachnoid hemorrhage (SAH) in 14 (53.8%), the multiple locations in 10 (38.5%) and a giant aneurysm in 4 (15.4%). Four de novo aneurysms were diagnosed in 3 patients (11.5%) after a mean follow-up of 22.3±4 years, which corresponds to an annual incidence of 1.9 (95% CI 1.4–2.6%). The transmission pattern was autosomal dominant in 16 (61.5%), recessive in 3 (11.5%) and not defined in 7 (26.9%). As regards the aortic diameter, a significant decrease in the aortic diameter was observed in patients with an aneurysmal diameter superior to 10mm. ConclusionThe rate of de novo aneurysm justifies prolonged monitoring by imaging of these patients with familial intracranial aneurysm. The narrowing of the terminal part of the aorta could be a hemodynamic factor involved into the IA development.