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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., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

An 82-year-old woman was admitted to our hospital with heart failure. Coronary angiography revealed one anatomically normal right coronary artery and three left coronary arteries (LCA-1, LSA-2, and LSA-3) separately originating from the right sinus of Valsalva, comprising multiple atherosclerotic lesions. LCA-1 became the obtuse marginal branch after branching off into the septal branches. LCA-2 was the main circumflex artery with an obstructive lesion. LCA-3 corresponded to the distal part of the anterior descending branch. The patient died 14 days after hospitalization. We describe the rarity of quadriostial origin, the unusual course, and the unusual branching of the coronary arteries.

Current knowledge of the aortic root geometric anatomy and its surgical implications remain limited. We analyzed multiple predefined parameters of the aortic root to increase our understanding of the geometric changes that occur in normal and aneurysmal transformations. Between November 2003 and September 2015, the aortic roots of 107 healthy subjects (control group) and 105 annuloaortic ectasia (AAE) patients (AAE group) were analyzed using multiplanar reformatted computed tomographic images. The intercommissural distance (ICD), sinus width (SW), and sinus volume (SV) of the left (LCS), right (RCS), and noncoronary sinuses (NCS) of Valsalva were adopted as study parameters. In the control group, all study parameters of the LCS were smaller than those of the RCS and the NCS. In the AAE group, all parameters of the LCS were significantly smaller than those of the RCS or NCS, but the RCS and NCS parameters were similar. Proportionately less LCS enlargement relative to either the RCS or NCS was observed in root aneurysm(AAE group) than in the control group. We observed a distinct aortic root geometric pattern which was characterized by the LCS being smaller than either the RCS or NCS, while the latter were similar. This geometric configuration was significantly accentuated in AAE patients due to the greater disproportionate disparity in the LCS relative to either the RCS or NCS than in the roots of normal control subjects. Clin. Anat. 32:117-123, 2019. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Background: Anomalous coronary artery origins appear in roughly 1% of coronary angiograms, and up to 15% of syncope and sudden cardiac death events can be attributed to anomalous coronaries. Patients with an anomalous coronary artery arising from the opposite sinus may initially present with syncope and electrocardiographic findings of ischemia., Case Report: We describe a case in which an adolescent male presented with exercise-induced angina and syncope, and his initial electrocardiogram (ECG) showed diffuse ST-segment depression with ST-segment elevation in lead aVR. Cardiac catheterization revealed there was no coronary ostium in the left coronary cusp, and the left coronary artery had an anomalous origin from the right cusp. The patient received urgent left internal mammary artery-to-left anterior descending artery coronary bypass and a saphenous vein graft to the ramus intermedius. After he underwent 6 months of medical therapy with β-blockade and angiotensin-receptor blockade, his left ventricular systolic function improved to low-normal level (left ventricular ejection fraction, approximately 50%). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ST-segment elevation in lead aVR is strongly prognostic for left main or triple-vessel coronary artery disease. However, in patients who present with syncope and few other coronary artery disease risk factors, this ECG finding should be suggestive of an ischemic event caused by an anomalous left coronary artery. Early recognition of this pattern of clinical signs and ECG findings by an emergency physician could be critical for making the correct diagnosis and risk stratifying the patient for early coronary angiography and urgent surgical revascularization., (Published by Elsevier Inc.)

Background: Ablation within the pulmonary sinus of Valsalva (PSV) becomes increasingly common in certain ventricular outflow arrhythmia. Understanding the regional anatomy is intensively concerned to avoid procedure complications., Purpose: To describe the anatomic relationships of PSV to its adjacent structures using computed tomographic coronary angiograms (CTCA)., Methods: We studied 145 patients (77 males, age 47 ± 18 years) investigated for chest pain with CTCA. The relationships between the PSV and adjacent structures were described by analysis of 2-dimensional images and 3-dimensional reconstructions., Results: The left adjacent sinus (LAS) was located within 5 mm of the left main coronary artery (LMCA) in 67% cases (19% within 2 mm) and within 5 mm of the left anterior descending coronary artery (LAD) in 87% (36% within 2 mm). The anterior sinus was within 5 mm of the LAD in 1% and out of 5 mm from LMCA in all cases. Note that 93% LAS was within 5 mm of the left aortic sinus of Valsalva (LASV) (within 2 mm in 27%), remaining 80% right adjacent sinus (RAS) within 5 mm from ascending aorta. The right coronary artery (RCA) was within 5 mm of the RAS/right ventricular outflow tract in 82% cases., Conclusions: Both the left and RASs are intimately related to the aortic root. The LAS is more often close to LMCA, LAD, and the LASV. The anterior sinus is more frequently related to LAD than LMCA. This information may help heighten operator awareness of safety for increasingly performed complex procedures in this area., (© 2018 Wiley Periodicals, Inc.)

Objective: It is intuitive to suggest that knowledge of the variation in the anatomy of the aortic root may influence the outcomes of transcatheter implantation of the aortic valve (TAVI). We have now assessed such variation., Methods: We used 26 specimens of normal hearts and 78 CT data sets of adults with a mean age of 64±15 years to measure the dimensions of the membranous septum and to assess any influence played by rotation of the aortic root, inferring the relationship to the atrioventricular conduction axis., Results: The aortic root was positioned centrally in the majority of both cohorts, although with significant variability. For the cadaveric hearts, 14 roots were central (54%), 4 clockwise-rotated (15%) and 8 counterclockwise-rotated (31%). In the adult CT cohort, 44 were central (56%), 21 clockwise-rotated (27%) and 13 counterclockwise-rotated (17%). A mean angle of 15.5° was measured relative to the right fibrous trigone in the adult CT cohort, with a range of -32° to 44.7°. The dimensions of the membranous septum were independent of rotation. Fibrous continuity between the membranous septum and the right fibrous trigone increased with counterclockwise to clockwise rotation, implying variation in the relationship to the atrioventricular conduction axis., Conclusions: The central fibrous body is wider, providing greater fibrous support, in the setting of clockwise rotation of the aortic root. Individuals with this pattern may be more vulnerable to conduction damage following TAVI. Knowledge of such variation may prove invaluable for risk stratification., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Aortic sinus dilatation can lead to aortic valve regurgitation or even aortic dissection. Our objective was to examine the association between body surface area (BSA) measures from childhood to middle age and aortic sinus diameter in middle age. Understanding the relation of these two clarifies how aortic size is normally determined., Methods: Cardiovascular Risk in Young Finns Study is a longitudinal study with follow-up of over 31 years (1980-2011). The study comprises information of body composition from multiple time points of 1950 subjects with cardiac ultrasound measurements made in 2011. The association between BSA in different ages and aortic sinus diameter in middle age was analysed by linear regression modelling adjusted with age, sex and diastolic blood pressure. Missing BSA values were derived for each life year (ages 3-33 years) from subject-specific curves for body weight and height estimated from longitudinal measurements using mixed model regression splines., Results: BSA estimates in early 20s are most strongly associated with aortic sinus diameter in middle age. Top association was observed at age 23 years with one SD increase in estimated BSA corresponding to 1.04 mm (0.87-1.21 mm) increase in aortic diameter. Increase in body weight beyond early 20s does not associate with aortic sinus diameter, and the association between middle age BSA and aortic size is substantially weaker (0.74 mm increase (0.58-0.89 mm)). These results were confirmed in a subpopulation using only measured data., Conclusion: The association between aortic sinus diameter and BSA is stronger when considering BSA in young adulthood compared with BSA in middle age., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Transcatheter aortic valve replacement (TAVR) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of inter-ethnic differences in valve morphology and function and aortic root dimensions in patients with BAV is important for the worldwide spread of this therapy in this subgroup of patients. Comparisons between large European and Asian cohorts of patients with BAV have not been performed, and potential differences between populations may have important implications for TAVR., Aim: The present study evaluated the differences in valve morphology and function and aortic root dimensions between two large cohorts of European and Asian patients with BAV., Methods and Results: Aortic valve morphology was defined on transthoracic echocardiography according to the number of commissures and raphe: type 0 = no raphe and two commissures, type 1 = one raphe and two commissures, type 2 = two raphes and one commissure. Aortic stenosis and regurgitation were graded according to current recommendations. For this study, aortic root dimensions were manually measured on transthoracic echocardiograms at the level of the aortic annulus, sinus of Valsalva (SOV), sinotubular junction (STJ), and ascending aorta (AA). Of 1427 patients with BAV (45.2 ± 18.1 years, 71.9% men), 794 (55.6%) were Europeans and 633 (44.4%) were Asians. The groups were comparable in age and proportion of male sex. Asians had higher prevalence of type 1 BAV with raphe between right and non-coronary cusps than Europeans (19.7% vs. 13.6%, respectively; P < 0.001), whereas the Europeans had higher prevalence of type 0 BAV (two commissures, no raphe) than Asians (14.5% vs. 6.8%, respectively; P < 0.001). The prevalence of moderate and severe aortic regurgitation was higher in Europeans than Asians (44.2% vs. 26.8%, respectively; P < 0.001) whereas there were no differences in BAV with normal function or aortic stenosis. After adjusting for demographics, comorbidities, and valve function, the dimensions of the aortic annulus [mean difference 1.17 mm/m2, 95% confidence interval (CI) 0.96-1.39], SOV (mean difference 1.86 mm/m2, 95% CI 1.47-2.24), STJ (mean difference 0.52 mm/m2, 95% CI 0.14-0.90) and AA (mean difference 1.05 mm/m2, 95% CI 0.57-1.52) were significantly larger among Asians compared with Europeans., Conclusions: This large multicentre registry reports for the first time that Asians with BAV showed more frequently type 1 BAV (with fusion between right and non-coronary cusp) and have larger aortic dimensions than Europeans. These findings have important implications for prosthesis type and size selection for TAVR.

Objectives: Previous studies using transthoracic echocardiography (TTE) observed moderate heritability of aortic root dimensions. Computed tomography angiography (CTA) might provide more accurate heritability estimates. Our primary aim was to assess the heritability of the aortic root with CTA. Our secondary aim was to derive TTE-based heritability and compare this with the CTA-based results., Methods: In the BUDAPEST-GLOBAL study 198 twin subjects (118 monozygotic, 80 dizygotic; age 56.1 ± 9.4 years; 126 female) underwent CTA and TTE. We assessed the diameter of the left ventricular outflow tract (LVOT), annulus, sinus of Valsalva, sinotubular junction and ascending aorta. Heritability was assessed using ACDE model (A additive genetic, C common environmental, D dominant genetic, E unique environmental factors)., Results: Based on CTA, additive genetic effects were dominant (LVOT: A = 0.67, E = 0.33; annulus: A = 0.76, E = 0.24; sinus of Valsalva: A = 0.83, E = 0.17; sinotubular junction: A = 0.82, E = 0.18; ascending aorta: A = 0.75, E = 0.25). TTE-derived measurements showed moderate to no genetic influence (LVOT: A = 0.38, E = 0.62; annulus: C = 0.47, E = 0.53; sinus of Valsalva: C = 0.63, E = 0.37; sinotubular junction: C = 0.45, E = 0.55; ascending aorta: A = 0.67, E = 0.33)., Conclusion: CTA-based assessment suggests that aortic root dimensions are predominantly determined by genetic factors. TTE-based measurements showed moderate to no genetic influence. The choice of measurement method has substantial impact on heritability estimates., Key Points: • Aortic root dimensions are determined by genetic and environmental effects. • Transthoracic echocardiography (TTE) demonstrated moderate to no genetic effects on aortic root dimensions. • Computed tomography angiography might provide more accurate heritability estimates compared to TTE. • Three-dimensional imaging techniques are needed to reliably quantify aortic root dimensions.

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.

Objective: The aim of this study was to characterize the cardiovascular and musculoskeletal systems of elite volleyball players, including aortic dimensions. Previous studies have shown that the upper limit of normal aortic sinus diameter for male and female athletes is 4 and 3.4 cm, respectively., Design: Cross-sectional analysis., Setting: United States Olympic Volleyball Training Facility and Rady Children's Hospital San Diego., Participants: Seventy (37 male) members of the US national volleyball team., Main Outcome Measures: Athletes underwent evaluation that included medical and family histories, targeted physical examinations specifically focusing on abnormalities present in Marfan syndrome (MFS), and transthoracic echocardiograms. Cardiac chamber and great artery size, valve function, and coronary artery origins were assessed., Results: Three male athletes (8%) had an aortic sinus diameter ≥4 cm, one of whom also had an ascending aorta >4 cm. Two female athletes (6%) had aortic sinus diameter ≥3.4 cm, and another had an ascending aorta of 3.4 cm. There were no other intracardiac or arterial abnormalities. Individual musculoskeletal characteristics of MFS were common among the athletes but not more frequent or numerous in those with aortic dilation., Conclusions: The prevalence of aortic root dilation in this population of athletes was higher than what has previously been reported in other similar populations. Further study is needed to determine whether these represent pathological changes or normal variations in tall athletes., Clinical Relevance: This study adds to the existing knowledge base of athlete's heart, with specific attention to aortic dimensions in elite volleyball players. The data are relevant to similar athletes' medical care and to preparticipation cardiac screening in general.

The characterization of the bileaflet mechanical heart valves (BMHVs) hinge microflow fields is a crucial step in heart valve engineering. Earlier in vitro studies of BMHV hinge flow at the aorta position in idealized straight pipes have shown that the aortic sinus shapes and sizes may have a direct impact on hinge microflow fields. In this paper, we used a numerical study to look at how different aortic sinus shapes, the downstream aortic arch geometry, and the location of the hinge recess can influence the flow fields in the hinge regions. Two geometric models for sinus were investigated: a simplified axisymmetric sinus and an idealized three-sinus aortic root model, with two different downstream geometries: a straight pipe and a simplified curved aortic arch. The flow fields of a 29-mm St Jude Medical BMHV with its four hinges were investigated. The simulations were performed throughout the entire cardiac cycle. At peak systole, recirculating flows were observed in curved downsteam aortic arch unlike in straight downstream pipe. Highly complex three-dimensional leakage flow through the hinge gap was observed in the simulation results during early diastole with the highest velocity at 4.7 m/s, whose intensity decreased toward late diastole. Also, elevated wall shear stresses were observed in the ventricular regions of the hinge recess with the highest recorded at 1.65 kPa. Different flow patterns were observed between the hinge regions in straight pipe and curved aortic arch models. We compared the four hinge regions at peak systole in an aortic arch downstream model and found that each individual hinge did not vary much in terms of the leakage flow rate through the valves.

Age-related morphological changes of the aorta, including dilatation and elongation, have been reported. However, rotation has not been fully investigated. We focused on the rotation of the ascending aorta and investigated its relationship with tortuosity. One hundred and two consecutive patients who underwent computed tomography coronary angiography were studied. The angle at which the en face view of the volume-rendered image of the right coronary aortic sinus (RCS) was obtained without foreshortening was defined as the rotation index. It was defined as zero if the RCS was squarely visible in the frontal view, positive if it rotated clockwise toward the left anterior oblique (LAO) direction, and negative if it rotated counter-clockwise toward the right anterior oblique (RAO) direction. The tortuosity was evaluated by measuring the biplane tilt angles formed between the ascending aorta and the horizontal line. The mean rotation index, posterior tilt angle viewed from the RAO direction (αRAO ), and anterior tilt angle viewed from the LAO direction (αLAO ) were 4.8 ± 16.3, 60.7 ± 7.0°, and 63.6 ± 9.0°, respectively. Although no correlation was observed between the rotation index and the αLAO (β = -0.0761, P = 0.1651), there was a significant negative correlation between the rotation index and αRAO (β = -0.1810, P < 0.0001). In multivariate regression analysis, the rotation index was an independent predictor of the αRAO (β = -0.1274, P = 0.0008). Clockwise rotation of the proximal ascending aorta exacerbates the tortuosity by tilting the aorta toward the posterior direction., (© 2014 Wiley Periodicals, Inc.)

Background and Aim of the Study: The effects of the implantation angle of bileaflet mechanical heart valves (BMHVs) on the sinus region and downstream flow profiles were investigated. Three-dimensional numerical simulations of BMHVs were performed under physiologic pulsatile flow conditions. The study aim was to examine how the flow fields of different aortic sinus shapes and the downstream aortic arch geometry would be affected by implantation angle., Methods: Two geometric models of sinus were investigated: a simplified axisymmetric sinus; and a three-sinus aortic root model, with two different downstream geometries, namely a straight pipe and a simplified curved aortic arch. A 29 mm St. Jude Medical BMHV geometric model was used and positioned at four different angles (0 degrees, 30 degrees, 60 degrees and 90 degrees)., Results: The simulation results showed variation in downstream flow profiles at different implantation angles. Generally, at position Z = 1D along the centerline (where Z refers to the axis normal to the x-y plane and D is the inlet diameter), the triple-jet structures were observed with a slight shift of the center jet for three-sinus aortic cases. Apparent differences were observed at position Z = 2D and 4D, such as higher velocity profiles at the inner arch wall. The flow field downstream of the valve implanted at 0 degrees (anatomic position) showed the smallest overall asymmetry at peak systole, while the flow field downstream of the valve implanted at 90 degrees (anti-anatomic position) exhibited high regions of recirculation., Conclusion: Valve orientation was found not to affect the shear stress distribution significantly in the downstream aorta, and this was in agreement with the findings of earlier studies.

The traditional route for teaching cardiac anatomy involves didactic instruction, cadaver dissections, and familiarization with the main structure and relationships of the cardiac chambers, valves, and vasculature. In contemporary cardiac electrophysiology, however, a very different view of anatomy is required including details rarely appreciated with a general overview. In this review, we discuss the critical advances in cardiac electrophysiology that were possible only because of understanding detailed anatomic relationships. While we briefly discuss the clinical relevance, we explain in depth the necessary structural information for the student of clinical anatomy. Interspersed through the text are boxes that highlight and summarize the critical pieces of knowledge to be borne in mind while studying the fascinating structural anatomy of the human heart., (© 2014 Wiley Periodicals, Inc.)

The aortic root is the anatomical bridge between the left ventricle and the ascending aorta. It is made up of the aortic valve leaflets, which are supported by the aortic sinuses (of Valsalva), and the interleaflet triangles interposed between the basal attachments of the leaflets. As such, it possesses significant length, and because of the semilunar attachment of the leaflets, there is no discrete proximal border to the root. It is limited distally, nonetheless, by the supravalvar ridge, or sinutubular junction. Descriptions of the aortic root over the years have been bedeviled by accounts of a valve anulus. There are at least two rings within the root, but neither serves to support the valve leaflets, each leaflets being attached in semilunar fashion from the sinutubular junction to a basal ventricular attachment Two leaflets are supported by muscle, and the third has an exclusively fibrous attachment. The root acts as a bridging structure not only anatomically, separating the myocardial and arterial components of the left ventricular pathway, but also functionally, since its proximal and distal components can withstand considerable changes in ventricular and arterial pressures. In this review, we describe the anatomy of this crucial cardiac component, emphasizing the current problems which have arisen due to indiscriminate descriptions of a nonexistent anulus., (Copyright © 2013 Wiley Periodicals, Inc.)

The anatomy of the sinuses of Valsalva has not been considered from the viewpoint of a converging nozzle. Converging nozzles reduce turbulence. We reviewed computed tomographic images of the left and right sinuses of Valsalva in 20 consecutive patients. The sinuses of Valsalva were shown to have a shape in the axial projection that approximates a cubic equation nozzle, although the sinuses of Valsalva are not axisymmetric. The ratios of the cross-sectional area of the inlet to cross-sectional areas of the outlet, assuming the sinuses are axisymmetric, were 14 and 17 in the left and right sinuses, respectively. Calculations by others show that turbulent kinetic energy at the exit (at the coronary ostia) of such axisymmetric nozzles would be reduced by 97%. We conclude that the sinuses of Valsalva have the configuration of a converging nozzle and prevent or reduce turbulent flow in the proximal portions of the coronary arteries., (© 2014 Anatomical Society.)

Understanding cardiac blood flow patterns has many applications in analysing haemodynamics and for the clinical assessment of heart function. In this study, numerical simulations of blood flow in a patient-specific anatomical model of the left ventricle (LV) and the aortic sinus are presented. The realistic 3D geometry of both LV and aortic sinus is extracted from the processing of magnetic resonance imaging (MRI). Furthermore, motion of inner walls of LV and aortic sinus is obtained from cine-MR image analysis and is used as a constraint to a numerical computational fluid dynamics (CFD) model based on the moving boundary approach. Arbitrary Lagrangian-Eulerian finite element method formulation is used for the numerical solution of the transient dynamic equations of the fluid domain. Simulation results include detailed flow characteristics such as velocity, pressure and wall shear stress for the whole domain. The aortic outflow is compared with data obtained by phase-contrast MRI. Good agreement was found between simulation results and these measurements.

This study presents a novel methodology for constructing an accurate geometrical model of a stentless aortic heart valve replacement (AVR). The main objective is to propose an optimized AVR model that can be used as an ideal scaffold for tissue engineering applications or a biocompatible prosthesis. Current techniques available for creating heart valve geometry, including leaflets, are very complicated and are not precise, due to the extensive use of various complicated parameters. This paper introduces an alternative design procedure that uses limited and effective numbers of controlling parameters to construct the whole valve including the sinus of valsalva. In doing so the hyperbolic curves for multithickness leaflets are used and a 3D elliptical formulation is incorporated for the surface geometry of the sinus of valsalva. Still, the feasibility and the precision of the mathematical method are established by performing standard deviation analysis on the constructed surfaces. The surface fitting residuals are found as low as error 0.2351 mm with standard deviation of 8.83e-5 over the commissural lines. Preliminary validation to the proposed AVR model performance is achieved by testing the generated AVR model under quasi static condition while obtaining the mesh independent setup. The numerical model showed a rapid response of the leaflets to the transvalvular pressure where adequate values of stress are measured over the commissural lines.

Background: The aorta is exposed to hemodynamic stress during exercise, but whether or not the aorta is larger in athletes is not clear. We performed a systematic literature review and meta-analysis to examine whethere athletes demonstrate increased aortic root dimensions compared with nonathlete controls., Methods and Results: We searched MEDLINE and Scopus from inception through August 12, 2012, for English-language studies reporting the aortic root size in elite athletes. Two investigators independently extracted athlete and study characteristics. A multivariate linear mixed model was used to conduct meta-regression analyses. We identified 71 studies reporting aortic root dimensions in 8564 unique athletes, but only 23 of these studies met our criteria by reporting aortic root dimensions at the aortic valve annulus or sinus of Valsalva in elite athletes (n=5580). Athletes were compared directly with controls (n=727) in 13 studies. On meta-regression, the weighted mean aortic root diameter measured at the sinuses of Valsalva was 3.2 mm (P=0.02) larger in athletes than in the nonathletic controls, whereas aortic root size at the aortic valve annulus was 1.6 mm (P=0.04) greater in athletes than in controls., Conclusions: Elite athletes have a small but significantly larger aortic root diameter at the sinuses of Valsalva and aortic valve annulus, but this difference is minor and clinically insignificant. Clinicians evaluating athletes should know that marked aortic root dilatation likely represents a pathological process and not a physiological adaptation to exercise.

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., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In-body tissue, architecture technology represents a promising approach for the development of living heart valve replacements and preparation of a series of biovalves. To reduce the degree of regurgitation and increase the orifice ratio, we designed a novel mold for a type VI biovalve. The mold had an outer diameter of 14 mm for implantation in beagles, and it was prepared by assembling two silicone rods with a small aperture (1 mm) between them. One rod had three protrusions of the sinus of Valsalva, whereas the other was almost cylindrical. When the molds were embedded in the subcutaneous pouches of beagles for 1 month, the native connective tissues that subsequently developed covered the entire outer surface of the molds and migrated into the aperture between the rods. The mold from both sides of the harvested cylindrical implant was removed, and homogenous well-balanced trileaflets were found to be separately formed in the open form with a small aperture at the three commissure parts inside the developed conduit, which had a thick homogenous wall even in the sinus of Valsalva. Exposure of the obtained biovalves to physiological aortic valve flow in beagles revealed proper opening motion with a wide orifice area. The closure dynamics were suboptimal, probably due to the reduction in the size of the sinus of Valsalva. The mechanical behavior of this biovalve might allow its use as a living aortic valve replacement., (Copyright © 2011 Wiley Periodicals, Inc.)

Aims: To report aortic root geometry by echocardiography in a large population of healthy, asymptomatic aortic stenosis (AS) patients in relation to current vendor-specified requirements for transcatheter aortic valve implantation (TAVI)., Methods and Results: Baseline data in 1481 patients with asymptomatic AS (mean age 67 years, 39% women) in the Simvastatin Ezetimibe in AS study were used. The inner aortic diameter was measured at four levels: annulus, sinus of Valsalva, sinotubular junction and supracoronary, and sinus height as the annulo-junctional distance. Analyses were based on vendor-specified requirements for the aortic root geometry for current available prostheses, CoreValve and Edwards-Sapien. The ratio of sinus of Valsalva height to sinus width was 1:2. In multivariate linear regression analysis, larger sinus of Valsalva height was associated with older age, larger sinus of Valsalva diameter, lower ejection fraction and smaller supracoronary diameter (multiple R(2) = 0.19, P< 0.01). The required annulus diameter for implantation of CoreValve was met in 61.9%, and for the Edwards-Sapien prosthesis in 66.9%. Overall, annular dimension feasible for TAVI using any available prosthesis was found in 78.2% of patients and in 77.7% of patients also the required minimum sinus of Valsalva height was found. Comparing the group of patients who met TAVI requirements to those who did not, the latter included more women and patients with lower body height and weight and significantly smaller aortic root diameters (all P < 0.05)., Conclusion: Among AS patients in the SEAS study, 27% of women and 19% of men did not have aortic root geometry fulfilling current requirements for TAVI.

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., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

A second right coronary artery is not at all unusual, as described here from Oxford, England.

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., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to determine whether atrial tachycardia arising adjacent to the noncoronary aortic sinus (NCAS-AT) has distinctive atrial activation patterns in relation to targeted anatomic imaging., Background: The knowledge of atrial activation patterns of the NCAS-AT and its anatomic basis is very limited., Methods: Three-dimensional electroanatomic mapping was performed during NCAS-AT in 13 patients and during sequentially pacing from the noncoronary aortic sinus (NCAS) and the para-Hisian atrial area in 15 reference patients. The spatial relationship between the NCAS and the contiguous atria was studied in another 25 reference patients using computed tomography and in 12 human hearts using gross and microscopic anatomic examination., Results: During NCAS-AT, the para-Hisian area of the right atrium (RA) and the anteroseptal region of the left atrium were activated almost simultaneously. The initial activation area (within first 20 ms of atrial depolarization) was relatively wide (9.3 +/- 2.6 cm(2) on the RA map and 8.1 +/- 2.1 cm(2) on the left atrium map). In reference patients, NCAS pacing reproduced a biatrial activation pattern of NCAS-AT and resulted in a wider initial activation area than the para-Hisian atrial pacing within first 20 ms of RA activation (10.1 +/- 3.0 cm(2) vs. 3.9+/-1.7 cm(2); p < 0.001). Anatomically, the wall of NCAS did not contain myocardial tissue, but was intimately related to the paraseptal regions of the atria such that the shortest distances from the NCAS to the RA and the left atrium were 1.7 +/- 0.6 mm and 2.3 +/- 0.9 mm (p < 0.01), respectively., Conclusions: NCAS-AT has distinct atrial activation patterns that can be explained in part by its spatial anatomic relationship with the atria., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Aim of the Study: Valve-sparing aortic root replacement techniques have been developed to treat sinus of Valsalva aneurysms. Finite-element models have been used to investigate the effects of altering sinus geometry and aortic root modulus on leaflet stress and strain, which may relate to long-term valve competence. However, these studies have assumed the same material properties for the ascending aorta and aortic sinuses. The study aim was to compare the material properties of the ascending aorta and aortic sinuses in porcine roots., Methods: Square specimens, oriented in the longitudinal and circumferential directions, were excised from porcine ascending aorta and aortic sinuses. Specimens were subjected to equibiaxial mechanical stretch testing. Stress-strain data from the aortic sinuses were fitted to a Fung form strain energy function, whereas ascending aortic data were fitted to a Hookean form. Tissue stiffness was compared at 0.35 Green strain., Results: The ascending aorta demonstrated a relatively linear response, unlike the non-linear response of the aortic sinuses. The ascending aorta was stiffer in the circumferential than the longitudinal direction (304.74 +/- 86.47 versus 249.38 +/- 69.81 kPa, p = 0.003), as was the aortic sinus (436.97 +/- 176.30 versus 393.24 +/- 156.10 kPa, p = 0.015). Compared to the sinuses, the ascending aorta was significantly more compliant in both longitudinal (p = 0.001) and circumferential (p = 0.007) directions., Conclusion: Both, the ascending aorta and aortic sinuses demonstrated anisotropy, with the circumferential direction stiffer than the longitudinal. However, the aortic sinuses were significantly stiffer than the ascending aorta. Finite-element modeling of the aortic root should incorporate such critical differences in the material properties.

Background: The anatomic value of the aortic root is important for aortic valve repair. This study was to determine the normal diameters of the aortic valve annulus (AVA) and sinus-tube joint (STJ) in the healthy adults of Chinese Han ethnic group, and to provide a morphological foundation for potential clinical application., Methods: Echocardiography was performed in 326 normal subjects, who were divided into 5 groups according to their age. The diameters of the AVA and STJ were measured in the parasternal long-axis view, and normalized to body surface area (BSA). They were averaged for each age group and for each gender. Differences were then determined between the normalized diameters for each age group and for both genders. Pearson's product-moment correlation coefficient was used to determine the differences between AVA and STJ diameters. It was also used to determine any positive or negative correlations between the above two variables and age, BSA, weight, and height., Results: The diameters of the AVA and STJ of Han nationality patients increased with an increase in age, BSA, weight, and height. The correlation coefficient between AVA diameter and BSA was 0.4944 (P < 0.0001), between AVA diameter and age, 0.1138 (P < 0.05), between AVA diameter and weight, 0.4521 (P < 0.001), and between AVA diameter and height, 0.4713 (P < 0.001). The correlation coefficient between STJ diameter and BSA was 0.3910 (P < 0.0001), between STJ diameter and age, 0.3667 (P < 0.0001), between STJ diameter and weight, 0.4586 (P < 0.0001), and between STJ diameter and height, 0.3736 (P < 0.0001). The difference between the above two diameters was statistically significant at 2.42 +/- 2.45 mm (paired t-test; t = -17.25; P < 0.0001). AVA and STJ diameters were similar in both genders of each group when indexed to BSA., Conclusions: The diameters of the AVA and STJ of adults of Chinese Han ethnic group increase with age, BSA, weight, and height. The diameters of the AVA and the STJ are similar in both genders, when indexed to BSA. The diameter of the AVA is shorter (about 10%) than that of the STJ, and the difference between the two diameters was 2.42 +/- 2.45 mm.

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.

Background and Aim of the Study: The three-dimensional motion of semilunar attachment of the leaflet 'annulus' remains obscure. It has been suggested that the aortic root is distensible and moves during the cardiac cycle. In the present study, the aortic root was evaluated using two dimensions. The aortic root, notably motion of the aortic annulus, was evaluated using multidetector computed tomography (MDCT), and a three-dimensional reconstruction of the aortic annulus was performed., Methods: Twenty-five patients (17 males, eight females) underwent MDCT. None of the patients had aortic root disease, aortic valve disease, bicuspid valve, myocardial infarction or atrial fibrillation. The aortic annulus was measured in systole and diastole, and divided into three parts: the right coronary cusp (RCC), left coronary cusp (LCC) and non-coronary cusp (NCC). The lengths of the aortic annulus, sinus of Valsalva and sinotubular junction (STJ) were also measured in systole and diastole on longitudinal views., Results: The lengths of each aortic annulus part in systole and diastole were as follows. In systole: RCC 41.8 +/- 8.1 mm; LCC 39.3 +/- 5.9 mm; NCC 43.7 +/- 7.1 mm. In diastole: RCC 42.4 +/- 7.0 mm; LCC 38.6 +/- 7.8 mm; NCC 41.5 +/- 7.8 mm. No statistically significant differences were observed between lengths in systole and diastole. The longitudinal lengths of aortic annulus, sinus of Valsalva and STJ at each period were as follows. In systole: aortic annulus 22.5 +/- 2.2 mm; sinus of Valsalva 34.9 +/- 4.3 mm; STJ 28.1 +/- 3.2 mm. In diastole: aortic annulus 22.1 +/- 2.2 mm; sinus of Valsalva 34.4 +/- 4.7 mm; STJ 27.2 +/- 3.1 mm. The length of the STJ in systole was significantly greater than that in diastole., Conclusion: In the normal aortic root, no part of the aortic annulus changed length during the cardiac cycle. According to changes in aortic root dimensions, the commissures move outwards during the systolic phase.

The morphometry of the intercommissural distances and their relation with other structures of the aortic valve of bovine heart was carried out. A total of 32 apparently healthy bovine hearts of indigenous cattle of both sexes (50% male and 50% female), 2-4 years of age, weighing 500 to 800 gms were used in this study. The external intercommissural distances were higher in all cusps of the valve compared to the internal intercommissural distances. The internal intercommissural distance was larger in the RC sinus in case of male animals followed by that of the LC and NC sinus. The mean external intercommissural distances were 34.67+/-3.40, 34.40+/-3.64 and 34.97+/-4.37 mm and the internal intercommissural distances were 21.60+/-4.21, 21.20+/-4.70 and 20.67+/-4.06 mm for LC, RC and NC respectively. Analyzing the internal intercommissural distance, value in the LC sinus was higher followed by the RC and the NC but this variation was non-significant. In regard to the position of the coronary ostia, there were two coronary ostia, the right coronary ostium present in the RC sinus and the left coronary ostium in the LC sinus respectively and the right coronary ostium was supracommissural in position in bovine heart. Data about the morphometrical analysis of intercommissural distances and the position of the coronary ostia of the aortic valve facilitate the knowledge of manufacturing bovine tissue valve as well as those might be involved in valve replacement in human.

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.

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.

Background and Aim of the Study: The presence of conformational changes in the aortic root during the cardiac cycle is well known, but precise information on time-related changes at each level of the root is lacking., Methods: High-resolution, 3D sonomicrometry (200 Hz) was applied in an acute sheep model. Twelve crystals were implanted in eight sheep at each base (n = 3), commissure (n = 3), sinotubular junction (n = 3) and ascending aorta (n = 3). Under stable hemodynamic conditions, geometric changes of the perimeter of each sinus of Valsalva, sinus height, and twist and root tilt angles were time-related to left ventricluar (LV) and aortic pressures., Results: Expansion of the perimeter of the three sinuses of Valsalva was homogeneous, but in significantly different proportions (p < 0.001): the right sinus expanded (+32.4 +/- 2.4%) more than the left (+29.3 +/- 3.2%), and more than the non-coronary (NC) sinus (+25.8 +/- 1.7%). A similar pattern was found for aortic root height: right greater than left, and left greater than NC sinus (p < 0.001). This asymmetry resulted in changes of the root's twist and tilt angles. Although the twist deformation was consistent for each sheep, no general pattern was found. The aortic root tilt angle (between the basal plane and the commissural plane) was 16.3 +/- 1.5 degrees at end-diastole (angle oriented posteriorly and to the left). During systole, it was reduced by 6.6 +/- 0.5 degrees, aligning the LV outflow tract with the ascending aorta. This tilt angle returned to its original value after valve closure., Conclusion: Aortic root expansion is asymmetric, generating precise changes in its tilt angle. During systole, tilt angle reduction resulted in a straight cylinder that probably facilitates ejection; during diastole, the tilt angle increased, probably reducing leaflet stress. These findings should impact upon surgical procedures and the design of new prostheses.

Idiopathic ventricular tachycardia originating from the left epicardium (Epi-VT) can be ablated from the left sinus of Valsalva (LSV) in selected patients. We hypothesized that the analysis of electrograms at the LSV and transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV) could predict the efficacy of radiofrequency catheter ablation (RFCA) from the LSV. Simultaneous mapping in the LSV and coronary venous system was performed in 25 patients (12 VTs and 13 premature ventricular contractions). The earliest ventricular activation (VA) during the arrhythmias was found at the LSV or GCV-AIV in all patients. RF applications from the LSV were successful in 17 patients success group (S-Gr) and failed in 8 failure group (F-Gr). The earliness of the VA recorded in the LSV (VA[LSV]) and in GCV-AIV (VA[GCV-AIV]) was compared between the two groups. (1) The VA[LSV] preceded the QRS onset by 28 +/- 11 ms in S-Gr and 14 +/- 10 ms in F-Gr (P < 0.01). (2) In S-Gr, the VA[GCV-AIV] was earlier than the VA[LSV] in 5 five patients (35%). However, in F-Gr, the VA[GCV-AIV] was earlier than the VA[LSV] in all patients. (3) In patients in whom the earliest VA was found at the LSV or GCV-AIV, a VA [GCV-AIV] preceding the VA[LSV] by less than 10 ms identified successful RFCA from the LSV with a sensitivity of 88 %, specificity of 100%, and high predictive value. With a detailed analysis of the electrograms recorded from the GCV-AIV and LSV, it was possible to identify the successful catheter ablation of Epi-VT from the LSV.

We estimated the frequency of anatomic variations in origin of the left coronary artery in a Turkish population by analyzing the angiographic data of 10,042 consecutive adult patients undergoing coronary angiography. Among 10,042 adult patients, 5 (0.04%) patients (4 men and 1 woman, age range 40-74, median 58 years old) had anomalous origin of the left main coronary artery. The left main coronary artery arose from the right coronary sinus of Valsalva in 2 (0.019%) patients (both of them had a retro-aortic course), from above the left coronary sinus of Valsalva in 2 (0.019%) patients, and from above the non-coronary (posterior)-left coronary commisure in 1 (0.009%) patient. Anomalous origin of the left main coronary artery is potentially a serious condition, as it can lead to myocardial infarction and sudden cardiac death under physical exertion. Therefore, greater effort for early detection and surgical repair of this anomaly are warranted. The angiographic recognition of anomalous origin of this vessel may prove useful for physicians dealing with diagnosis and treatment of anomalies of the left main coronary artery.

Investigations were carried out on 55 monkey (Cercopithecus aethiops, Macaca fascicularis) hearts by stereomicroscopic dissection and measurements. Latex-injected specimens and corrosion casts showed that, as in humans, the hearts were usually (in 98.2% of the cases) supplied by two coronary arteries (CAs)--the left (LCA) and the right coronary artery (RCA), and occasionally (in 1.8% of the cases) also by a third one (TCA). Furthermore, the orifice of the TCA was situated in the right aortic sinus at the same level as the RCA and 0.2 mm in front of it. The LCA and the RCA originated from the corresponding aortic sinuses and the external diameter of the LCA was greater [average: 1.65+/-0.39 (SD) mm] than that of the RCA [average 0.94+/-0.15 (SD) mm] and the TCA (0.8 mm). The LCA orifice was more often above (76.3%) than below the free edge of the left aortic valve leaflet. The longitudinal axis of the aortic root and of the initial part of the LCA formed an angle of 45-120 degrees (average: 52 degrees). The orifice of the RCA was usually above (82.3%) the free edge of the right aortic valve leaflet, and less frequently below it (17.7%). The longitudinal axis of the aortic root and of the initial part of the RCA formed an angle of 70-150 degrees (average: 103 degrees). The resemblance of monkey CAs to their human counterparts make them a suitable model for experimental studies on coronary circulation.

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.

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

Background and Aims of the Study: Growing interest in aortic root replacement with the use of stentless auto-, homo- and xenografts, and new developments in aortic valve conservation demand a deeper understanding of the normal aortic root anatomy., Methods: Ten cryopreserved human aortic roots were pressurized, fixed and measured directly (leaflet free edge and attachment) and using three-dimensional computed tomography imaging software (sinus of Valsalva height and volume)., Results: The mean of the measurements of all four parameters yielded a pattern in which the non-coronary sinus (N) structures had the greatest dimensions followed by the right (R) and then the left (L). Non-parametric ANOVA on each of these parameters also showed significant differences among the sinuses yielding a pattern of N > R > L. This pattern determined an angle of tilt between the plane at the base (annulus) and the plane intersecting the sinotubular junction with a mean value of 11 degrees. Linear regression indicated that this angle did not depend on the size of the base (annulus)., Conclusions: The data showed a geometric pattern of the aortic root, with the structures of the non-coronary sinus being the largest followed by the right and then the left. The possible hemodynamic relevance and surgical implications of these findings need to be explored.

This anatomic study realized on 40 African adults hearts, studies the veins related to the coronary sinus. By using injection of the coronary arteries and corrosion of the myocardium, this study discovers certain particularities of the small coronary vein and of the posterior descending interventricular vein in Africans.