Functional Aortic Valve Complex
The aortic root is the tubular structure between the left ventricular outflow tract (LVOT) and the ascending aorta (Fig 1). The lower margin is the ventriculo-aortic junction (VAJ), the upper margin is the sinotubular junction (STJ), and the bulging sinuses are in between.
In contrast to a single planar insertion of mitral leaflets, each aortic valve leaflet has a curvilinear attachment starting from the STJ, going across the sinus to the VAJ, and back up to the STJ (Fig 2). The nadir of each leaflet sways away from the actual VAJ to a varying extent. The actual nadir of the three leaflets is called the virtual basal ring (VBR). The aortic valve leaflets and the aortic root form the “functional aortic valve complex”.
The two adjacent leaflet attachments at the STJ form the commissures. The free margin of each leaflet extends from one commissure to the other. The contiguous margins of the leaflets coapt together bringing valve competence (Fig 3).
For a competent valve, the three leaflets must be at the same level and of a sufficient height, allowing them to coapt together (Fig 4).
Tricuspid and Bicuspid Valves
The most common configuration of the aortic valve is tricuspid.
Bicuspid aortic valve (BAV) is present in about 2% of the population. It is the most common congenital cardiac anomaly and has a 3:1 male predominance. Most patients with BAV develop some type of complication during their lifetime either from valve dysfunction or from enlargement of the aorta (aortopathy). The valve dysfunction can be either aortic stenosis (AS), aortic insufficiency (AI) or mixed AS/AI and can present at any age of the life. The average age of BAV patients with predominant AS is 65 yrs. Those with AI present at an earlier age (average 46 years) and is usually associated with VAJ dilatation1.
About 30% of BAV patients present with aortopathy in various combinations of enlargement of the aortic sinuses, ascending aorta and aortic arch2.
Quadricuspid and Unicuspid Valves
Unicuspid and quadricuspid configurations (Fig 5) are less common than bicuspid valves.
Unicuspid valve has a single functioning commissure and is frequently misdiagnosed as Sievers type 2 bicuspid. Some young patients with localized calcification may be candidates for repair in expert hands.
Quadricuspid valve is the least common variety and is usually associated with AI and can be repaired.
|Fig 5: Tricuspid, bicuspid, unicuspid and quadricuspid valves
Sabet HY, Edwards WD, Tazelaar HD, Daly RC. Congenitally bicuspid aortic valves: a surgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 additional cases. Mayo Clin Proc. 1999;74:14–26.
Aortic stenosis (AS) is the most common valvular abnormality in adult patients. Aortic stenosis is currently treated by replacing the aortic valve by surgical (SAVR) or transcatheter approach (TAVR).
Calcific Tricuspid and Bicuspid Aortic Stenosis (Fig 6)
Aortic insufficiency (AI): Any condition that causes the leaflets not to come together, either because of a change in root dimensions (enlarged STJ or enlarged VAJ) or shortening or elongation of the leaflet free margins causes valve incompetence (Fig 7).
Ramesh Veeragandham, M.D.
Dr. Veeragandham completed his general surgery residency at the University of California, San Diego and a cardiovascular and thoracic surgery fellowship at Rush Presbyterian Medical Center in Chicago. He is the Co-Director of Cardiac Surgery for John Muir Health. Dr. Veeragandham specializes in aortic valve repairs, aortic aneurysms, adult cardiac surgery, minimally invasive valve surgery and endovascular surgery. He conducts medical missions for heart surgery for poor patients in India.
Prof. Dr. med. Hans-Joachim Schäfers
Prof. Schäfers completed his general surgery residency, and his thoracic and cardiovascular surgery at Hannover Medical School in Hannover, Germany. He currently serves as the Director for the Department of Thoracic and Cardiovascular Surgery at University Hospitals of Saarland in Homburg, Germany. Prof. Schäfers is one of the most experienced cardiac surgeons in the world in performing aortic valve repairs and has published extensively on this topic. He is available to provide input and feedback to our cardiac surgeons in patient selection, and to proctor aortic valve repair surgeries in real-time via teleconferencing technology.
Jatinder Dhillon, M.D.
Dr. Jatinder Dhillon completed his general surgery residency at the University of Hawaii in Honolulu, his cardiothoracic surgery residency at the University of New Mexico in Albuquerque and his fellowship in cardiothoracic surgery at Beth Israel Hospital, Harvard Medical School. He serves as the Co-Director of Cardiac Surgery for John Muir Health. Dr. Dhillon specializes in vascular surgery, thoracic surgery and adult cardiac surgery including minimally invasive cardiac valve surgery and atrial fibrillation surgery.
Murali Dharan, M.D.
Dr. Murali Dharan completed his general surgery residency at the University of California, San Diego, and his cardiothoracic surgery fellowship at University of California, Los Angeles. Dr Dharan specializes in adult cardiac surgery, complex minimally invasive mitral valve repair, and tricuspid valve surgery. He has pioneered innovative approaches in minimally invasive mitral valve surgery and cardiothoracic surgery. He frequently leads a team of volunteers performing complex cardiac surgery in the Dominican Republic.
Andreas Kamlot, M.D.
Dr. Andreas Kamlot completed his general surgery residency at Cedars Sinai Medical Center in Los Angeles, and his cardiothoracic surgery fellowship at the University of Southern California in Los Angeles. Dr. Kamlot specializes in adult cardiac surgery and minimally invasive cardiac surgery including valve repair and atrial fibrillation surgery.
Tanveer Khan, M.D.
Dr. Tanveer Khan completed his general surgery residency at Harvard Medical School and his cardiothoracic surgery fellowship at the University of California, Los Angeles. He also completed an endovascular fellowship at Stanford University School of Medicine and a transplant and adult cardiac surgery fellowship at the University of California, Los Angeles. Dr. Khan specializes in adult cardiovascular surgery and endovascular surgery including aortic stent grafts.
Bicuspid Aortic Valve Repair with Root Remodeling
Bicuspid Aortic Valve Repair-Normal Root
Tricuspid Aortic Valve Repair with Root Remodeling
Tricuspid Aortic Valve Repair-Normal Root
View Richard’s story about his severely leaky aortic valve and enlarging heart.
View Tammy’s story about her journey and recovery from an aortic aneurysm and a leaky aortic valve.
View Puneet’s story about his journey and recovery from an aortic aneurysm and a significantly leaky bicuspid aortic valve.
View Shelley’s story about the complex repair of her bicuspid aortic valve.