Anatomy of the Aortic Valvar Complex and Its Implications for Transcatheter Implantation of the Aortic Valve

Abstract

Abstract-The books and articles devoted to the anatomy of the aortic valvar complex are numerous. Until now, however, little consideration has been given to understanding the anatomy with percutaneous valvar replacement in mind. It is axiomatic that knowledge of the anatomy of the valve is fundamental in understanding key principles involved in valvar replacement. Such an appreciation of the anatomy helps better understand the optimal positioning for the prosthetic valve within the root of the aorta with respect to the coronary arteries, mitral valve, and the conduction system and may circumvent complications that can arise during its implantation. In this review, therefore, we describe the anatomy of the trifoliate aortic valvar complex and its implications for percutaneous valvar replacement. Key Words: anatomy Ⅲ aorta Ⅲ catheters Ⅲ stenosis Ⅲ valves T he realization that it is now possible to replace the aortic valve percutaneously has created awareness among cardiologists of the importance in the anatomy of the aortic valvar complex. The earliest documented interest in the anatomy of the aortic valvar complex stems from the Renaissance, with the description and drawings by Leonardo da Vinci (1513). The books and articles devoted to this topic are numerous. [1][2][3][4] . Until now, however, little consideration has been given to understanding the anatomy with percutaneous valvar replacement in mind. There are a number of designs for valves that can be inserted percutaneously in aortic position, but thus far most experience has been gained using the Edwards SAPIEN prosthetic heart valve or the CoreValve ReValving System. [5][6][7] Implantation is achieved by either a transfemoral or transapical approach. Generally speaking, the prosthesis is positioned within the aortic root and, once deployed, crushes the leaflets of the native valve against the wall. It is axiomatic that knowledge of the anatomy of the valve is fundamental in understanding key principles involved in valvar replacement. Such an appreciation of the anatomy helps better to understand the optimal positioning for the prosthetic valve within the aortic root with respect to the coronary arteries, mitral valve, and the conduction system, and may circumvent complications that can arise during its implantation. In addition, the need for accurate knowledge of the aortic valvar complex is imperative, not only as percutaneous therapies of the aortic valve become clinically established but also in the new design and refinements of current valvar technology. In this review, therefore, we describe the anatomy of the trifoliate aortic valvar complex and its implications for percutaneous valvar replacement. The presence of an aortic valve with 2 leaflets is currently considered a contraindication to transcatheter implantation of the aortic valve. This topic, therefore, although of unequivocal importance, has been omitted, in the interest of brevity, from our discussion of the anatomy of the aortic valvar complex. Description of the Type of Transcatheter Aor...

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“…The proximal border is the ventriculoarterial junction (VAJ), which has hemodynamic and anatomic parts. The hemodynamic part is marked by the semilunar attachments of the cusps, whereas the anatomical part is marked by the circular attachment of the proximal aorta, the muscular and membranous ventricular septum (Lawrence H. Cohn, 2012;Piazza et al, 2008 …”