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SURGICAL ANATOMY OF THE AORTIC ROOT IN THE ASPECT OF ITS RECONSTRUCTION

https://doi.org/10.17802/2306-1278-2025-14-1-91-102

Abstract

Highlights

The presented literature review contains anatomical and topographic features of the aortic root, knowledge of which is necessary for its successful reconstruction.

 

Abstract

The purpose of this literature review is to study and determine the anatomical features of the structures and topography of the aortic root in the perspective of a reconstructive surgical approach in the treatment of the proximal thoracic aorta. A review was conducted on the anatomy and topography of the aortic root in non-operated patients, without signs of its dilation using radiation, functional diagnostic methods, as well as studies conducted on heart preparations obtained from patients who died of non-cardiac causes. The surgical features of performing reconstructive interventions on the aortic root, taking into account the peculiarities of its anatomy, are also considered. The area of the aortic root is anatomically variable, depending on anthropometric data, race, gender, etc. To successfully perform the reconstruction of the aortic root, it is necessary to achieve certain indexed values between its structures. Absolute knowledge and understanding of the surgical anatomy of the aortic root are necessary for the successful implementation of its reconstruction.

About the Authors

Vladimir K. Noginov
Federal State Budgetary Educational Institution of Higher Education “Saint Petersburg State Pediatric Medical University” of the Ministry of Health of the Russian Federation; State Budgetary Healthcare Institution Leningrad Regional Clinical Hospital
Russian Federation

Assistant Professor at the Department of Operative Surgery and Topographic Anatomy named after Professor F. I. Walker of the Federal State Budgetary Educational Institution of Higher Education "St. Petersburg State Pediatric Medical University" of the Ministry of Health of the Russian Federation, St. Petersburg, Russian Federation; cardiovascular surgeon at the Cardiac Surgery Department of the State Budgetary Healthcare Institution "Leningrad Regional Clinical Hospital hospital", Saint Petersburg, Russian Federation



Roman N. Komarov
Federal State Autonomous Educational Institution of Higher Education “I.M. Sechenov First Moscow State Medical University” of the Ministry of Health of the Russian Federation
Russian Federation

PhD, MD, Professor, Head of the Department of Faculty Surgery No. 1 of the N. V. Sklifosovsky Institute of Clinical Medicine of the Federal State Autonomous Educational Institution of Higher Education "I.M. Sechenov First Moscow State Medical University" of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian Federation



Georgy O. Bagaturia
Federal State Budgetary Educational Institution of Higher Education “Saint Petersburg State Pediatric Medical University” of the Ministry of Health of the Russian Federation
Russian Federation

PhD, MD, Professor, Head of the Department of Operative Surgery and Topographic Anatomy named after Prof. F.I. Walker Federal State Budgetary Educational Institution of Higher Education "St. Petersburg State Pediatric Medical University" of the Ministry of Health of the Russian Federation, St. Petersburg, Russian Federation



Andrey N. Dzyunja
Federal State Autonomous Educational Institution of Higher Education “I.M. Sechenov First Moscow State Medical University” of the Ministry of Health of the Russian Federation
Russian Federation

Cardiovascular Surgeon, Federal State Autonomous Educational Institution of Higher Education "I.M. Sechenov First Moscow State Medical University", Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian Federation



Marina Lenkovets
Federal State Autonomous Educational Institution of Higher Education “I.M. Sechenov First Moscow State Medical University” of the Ministry of Health of the Russian Federation
Russian Federation

Cardiovascular surgeon, Postgraduate student at the Department of Faculty Surgery No. 1 of the N.V. Sklifosovsky Institute of Clinical Medicine of the Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian Federation



References

1. De Paulis R., Salica A. Surgical anatomy of the aortic valve and root-implications for valve repair. Annals of cardiothoracic surgery. 2019 May;8(3):313-321. doi: 10.21037/acs.2019.04.16. PMID: 31240175

2. Paiocchi V.L., Faletra F.F., Ferrari E., Schlossbauer S.A., Leo L.A., Maisano F.. Multimodality imaging of the anatomy of the aortic root. Journal of cardiovascular development and disease. 2021 May 4;8(5):51. PMID: 34064421. doi: 10.3390/jcdd8050051

3. Irace F.G., Chirichilli I., Salica A., D’Aleo S., Wolf L.G., Garufi L., De Paulis R.. Aortic root anatomy after aortic valve reimplantation. The journal of thoracic and cardiovascular surgery. 2021 Apr 16;S0022-5223(21)00695-4. PMID: 33985805. DOI: 10.1016/j.jtcvs.2021.03.115.

4. Almoosawy. S.A., Lucka P., Cummine R., Buchan K.. The aortic root hexagon as an aide memoire to the important surgical landmarks. Clinical anatomy. 2020 Nov;33(8):1228-1234. PMID: 31983068. DOI: 10.1002/ca.23571

5. Lansac E., Lim H-S., Shomura Y., Lim K.H., Rice N.T., Di Centa I., Youssefi P., Goetz W., Doran C.M.G.. Aortic valve opening and closure: the clover dynamics. Annals of cardiothoracic surgery. 2019 May;8(3):351-361. PMID: 31240179. DOI: 10.21037/acs.2019.05.03.

6. Koshkelashvili N., Bucay M.J., Goykhman I., Pressman G.S.. Aortic root and valve proportions: an example of the golden ratio? Monaldi archives for chest disease. 2019 Jul 15;89(2). PMID: 31315350. DOI: 10.4081/monaldi.2019.1022.

7. Wang X., Ren X-S., An Y-Q., Hou Z-H., Yu Y-T., Lu B., Wang F.. A specific assessment of the normal anatomy of the aortic root in relation to age and gender. International journal of general medicine. 2021 Jun 25;14:2827-2837. PMID: 34234516. DOI: 10.2147/IJGM.S312439

8. Petersen J., Voigtlander L., Schofer N., Neumann N., von Kodolitsch Y., Reichenspurner H., Girdauskas E.. Geometric changes in the aortic valve annulus during the cardiac cycle: impact on aortic valve repair. European journal of cardio-thoracic surgery. 2018 Sep 1;54(3):441-445. PMID: 29514226. DOI: 10.1093/ejcts/ezy099

9. Yacoub M.H., Aguib H., Gamrah M.A., Shehata N., Nagy M., Donia M., Aguib Y., Saad H., Romeih S., Torii R., Afifi A., Lee. S-L.. Aortic root dynamism, geometry, and function after the remodeling operation: Clinical relevance. The Journal of thoracic and cardiovascular surgery. 2018 Sep;156(3):951-962.e2. PMID: 29884493. DOI: 10.1016/j.jtcvs.2018.03.157.

10. O’Brien, B.; Zafar, H.; De Freitas, S.; Sharif, F. Transseptal Puncture—Review of Anatomy, Techniques, Complications and Challenges. International journal of cardiology. 2017 Apr 15;233:12-22. PMID: 28202256. doi: 10.1016/j.ijcard.2017.02.009

11. El Khoury G., Glineur D., Rubay J., Verhelst R., d'Udekem d'Acoz Y., Poncelet A., Astarci P., Noirhomme Ph., van Dyck M.. Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures. Current opinion in cardiology. 2005 Mar;20(2):115-21. PMID: 15711197. doi: 10.1097/01.hco.0000153951.31887.a6

12. Kunihara T. Anatomy of the aortic root: implications for aortic root reconstruction. General thoracic and cardiovascular surgery. 2017 Sep;65(9):488-499. PMID: 28656518. DOI: 10.1007/s11748-017-0792-y

13. Mori S., Izawa Y., Shimoyama S., Tretter J.T.. Three-Dimensional Understanding of Complexity of the Aortic Root Anatomy as the Basis of Routine Two-Dimensional Echocardiographic Measurements. Circulation journal. 2019 Oct 25;83(11):2320-2323. PMID: 31511440. DOI: 10.1253/circj.CJ-19-0652

14. Toh H., Mori S., Tretter J.T., Izawa Y., Shimoyama S., Suzuki M., Takahashi Y., Tsuda D., Toba T., Fujiwara S., Hirata K., Anderson R.H.. Living Anatomy of the Ventricular Myocardial Crescents Supporting the Coronary Aortic Sinuses. Seminars in thoracic and cardiovascular surgery. 2020 Summer;32(2):230-241. PMID: 31954834. DOI: 10.1053/j.semtcvs.2020.01.001

15. Yamada T, Lau YR, Litovsky SH, et al: Prevalence and clinical, electrocar- diographic, and electrophysiologic characteristics of ventricular arrhyth- mias originating from the noncoronary sinus of Valsalva. Heart Rhythm 10:1605–1612, 2013

16. De Kerchove L., Jashari R., Boodhwani M., Duy K.T., Lengele B., Gianello P., Nezhad Z.M., Astarci P., Noirhomme P., El Khoury G.. Surgical anatomy of the aortic root: Implication for valve-sparing reimplantation and aortic valve annuloplasty. The Journal of thoracic and cardiovascular surgery. 2015 Feb;149(2):425-33. PMID: 25439782. DOI: 10.1016/j.jtcvs.2014.09.042

17. O’Connor S.A., Morice M.C., Gilard M., Leon M.B., Webb J.G., Dvir D., Rodés-Cabau J., Tamburino C., Capodanno D., D’Ascenzo F., Garot P., Chevalier B., Mikhail G.W., Ludman P.F.. Revisiting sex equality with transcatheter aortic valve replacement outcomes: a collaborative, patient-level meta-analysis of 11,310 patients. Journal of the American College of Cardiology. 2015 Jul 21;66(3):221-228. PMID: 26184614. DOI: 10.1016/j.jacc.2015.05.024.

18. Du F., Liu X., Zhu Q., He Y., Jiang J., Napawan T., Jaiswal S., Chen Z., Wang J.. Sex-specific aortic root anatomy in patients with bicuspid aortic valve undergoing TAVR in a Chinese cohort. Herz. 2020 Jun;45(4):375-381. PMID: 30483815. DOI: 10.1007/s00059-018-4740-0

19. Contino M., Mangini A., Lemma M.G., Romagnoni C., Zerbi P., Gelpi G., Antona C.. A geometric approach to aortic root surgical anatomy. European journal of cardio-thoracic surgery. 2016 Jan;49(1):93-100. PMID: 25724903. DOI: 10.1093/ejcts/ezv059.

20. Mori S, Anderson RH, Tahara N, et al. The differences between bisecting and off-center cuts of the aortic root: the three-dimensional anatomy of the aortic root reconstructed from the living heart. Echocardiography 2017 Mar;34(3):453-461.doi: 10.1111/echo.13468. PMID: 28160343.

21. Federspiel J.M., Ehrlich T., Abeln K., Schäfers H-J.. Aortic annuloplasty: Subcomissural, intra-annular suture techniques, external and internal rings. JTCVS Techniques. 2021. Jun; 7: 98–102. PMID: 34318215. doi: 10.1016/j.xjtc.2020.12.044

22. Youssefi P., Lansac E.. Aortic annulus and the importance of annuloplasty. Indian journal of thoracic and cardiovascular surgery. 2020 Jan;36(Suppl 1):88-96. PMID: 33061189. doi: 10.1007/s12055-019-00852-9

23. Izawa Y., Mori S., Tretter J.T., Quintessenza J.A., Toh H., Toba T., Watanabe Y., Kono A.K., Okada K., Hirata K-I.. Normative aortic valvar measurements in adults using cardiac computed tomography - a potential guide to further sophisticate aortic valve-sparing surgery. Circulation journal. 2021 Jun 25;85(7):1059-1067. PMID: 33408304. DOI: 10.1253/circj.CJ-20-0938.

24. Randhawa A., Gupta T., Singh P., Aggarwal A., Sahni D.. Description of the aortic root anatomy in relation to transcatheter aortic valve implantation. Cardiovascular pathology. 2019 May-Jun;40:19-23. PMID: 30772639. DOI: 10.1016/j.carpath.2019.01.005

25. Kheradvar A., Vannan M.A., Lakshmi P.D., Pedrizzetti G.. The effect of aortic root anatomy vortex flow induced shear stress on the aortic valve leaflets. European heart journal. Cardiovascular Imaging. 2021 Aug 14;22(9):995-997. PMID: 33758910. DOI: 10.1093/ehjci/jeab031.

26. Nasr A.Y., Tahlawi M.E.. Anatomical and radiological angiographic study of the coronary ostia in the adult human hearts and their clinical significance. Anatomy & cell biology. 2018 Sep;51(3):164-173. PMID: 30310708. DOI: 10.5115/acb.2018.51.3.164.

27. Agrawal R. Anatomical study of coronary ostia in cadaveric hu man heart. Global Journal For Research Analysis. 2018 Mar; 7(3): 23-25.

28. Smettei O.A., Sayed S., Abazid R.M.. The prevalence of coronary artery anomalies in Qassim Province detected by cardiac computed tomography angiography. Journal of the Saudi Heart Association. 2017 Apr;29(2):84-89. PMID: 28373781. DOI: 10.1016/j.jsha.2016.07.006.

29. Villa A.D., Sammut E., Nair A., Rajani R., Bonamini R., Chiribiri A.. Coronary artery anomalies overview: the normal and the abnormal. World J Radiol. 2016;8:537–55.

30. Fujiyoshi T., Matsumoto R., Kamiya K., Ogino H.. Inter‐operative determination of the aortic root and cusp geometry associated with the aortic regurgitation grade. Surgery today. 2021 Mar;51(3):384-390. PMID: 32776293

31. De Kerchove L., Momeni M., Aphram G., Watremez C., Bollen X., Jashari R., Boodhwani M., Astarci P., Noirhomme P., El Khoury G.. Free margin length and coaptation surface area in normal tricuspid aortic valve: an anatomical study. European journal of cardio-thoracic surgery. 2018 May 1;53(5):1040-1048. PMID: 29253123. DOI: 10.1093/ejcts/ezx456

32. Komiya T., Shimamoto T., Nonaka M., Matsuo T.. Is small cusp size a limitation for aortic valve repair? European journal of cardio-thoracic surgery. 2019 Sep 1;56(3):497-502. PMID: 30824918. DOI: 10.1093/ejcts/ezz053.

33. Khelil N., Sleilaty G., Palladino M., Fouda M., Escande R., Debauchez M., Di Centa I., Lansac E.. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. The Annals of thoracic surgery. 2015 Apr;99(4):1220-6. PMID: 25728963. DOI: 10.1016/j.athoracsur.2014.12.034.

34. Schäfers Р-J., Schmied W., Marom G., Aicher D.. Cusp height in aortic valves. The Journal of thoracic and cardiovascular surgery. 2013 Aug;146(2):269-74. PMID: 22853942. DOI: 10.1016/j.jtcvs.2012.06.053.

35. Yang T., Wen H., El-Hamamsy I., Ni Q., Sun Y., Zhu D.. Relationship between leaflets and root in normal aortic valve based on computed tomography imaging: implication for aortic valve repair. Frontiers in cardiovascular medicine. 2021 Nov 22;8:731440. PMID: 34881298. DOI: 10.3389/fcvm.2021.731440.

36. Abeln K.B., Giebels C., Ehrlich T., Federspiel J.M., Schäfers H-J.. Which Aortic Valve Can Be Surgically Reconstructed? Current cardiology reports. 2021 Jul 2;23(8):108. PMID: 34213661. DOI: 10.1007/s11886-021-01525-z.

37. Chirichilli I., Irace F., Weltert L., Tsuda K., Scaffa R., Salica A., Galea N., De Paulis R.. Morphological modification of the aortic annulus in tricuspid and bicuspid valves after valve reimplantation: an electrocardiography-gated computed tomography study. European journal of cardio-thoracic surgery. 2019 Oct 1;56(4):778-784. PMID: 30859210. DOI: 10.1093/ejcts/ezz065.

38. Kong W.K.F., Regeer M.V., Poh K.K., Yip J.W., van Rosendael P.J., Yeo T.C., Tay E., Kamperidis V., van der Velde E.T., Mertens B., Marsan N.A., Delgado V., Bax J.J..Inter-ethnic differences in valve morphology, valvular dysfunction, and aortipathy between Asian and European patients with bicuspid aortic valve. European heart journal. 2018 Apr 14;39(15):1308-1313. PMID: 29029058. DOI: 10.1093/eurheartj/ehx562

39. Rodríguez-Palomares J.F., Dux-Santoy L., Guala A., Kale R., Maldonado G., Teixidó-Turà G., Galian L., Huguet M., Valente F., Gutiérrez L., González-Alujas T., Johnson M.K., Wieben O., García-Dorado D., Evangelista A.. Journal of cardiothoracic magnetic resonance. 2018 Apr 26;20(1):28. PMID: 29695249. DOI: 10.1186/s12968-018-0451-1.

40. Komarov R.N., Noginov V.K. The possibilities of valve-sparing surgical treatment of bicuspid aortic valve syndrome. Patologiya krovoobrashcheniya i kardiokhirurgiya = Circulation Pathology and Cardiac Surgery. 2022;26(2):9-16. (In Russ.) https://dx.doi.org/10.21688/1681-3472-2022-2-9-16.

41. Mahadevia R., Barker A.J., Schnell S., Entezari P., Kansal P., Fedak P.W., Malaisrie S.C., McCarthy P., Collins J., Carr J., Markl M.. Bicuspid aortic cusp fusion morphology alters aortic three-dimensional outflow patterns, wall shear stress, and expression of aortopathy. Circulation 2014 Feb 11;129(6):673-82. PMID: 24345403. DOI: 10.1161/CIRCULATIONAHA.113.003026.

42. Della Corte A., Bancone C., Dialetto G., Covino F.E., Manduca S., Montibello M.V., De Feo M., Buonocore M., Nappi G.. The ascending aorta with bicuspid aortic valve: a phenotypic classification with potential prognostic significance. European journal of cardio-thoracic surgery. 2014 Aug;46(2):240-7. PMID: 24431175. DOI: 10.1093/ejcts/ezt621

43. Shaefer B.M., Lewin M.B., Stout K.K., Gill E., Prueitt A., Byers P.H., Otto C.M.. The bicuspid aortic valve: an integrated phenotypic classification of leaflet morphology and aortic root shape. Heart. 2008 Dec;94(12):1634-8. PMID: 18308868. DOI: 10.1136/hrt.2007.132092.

44. Park C.B., Greason K.L., Suri R.M., Michelena H.I., Schaff H.V., Sundt 3rd T.M.. Fate of nonreplaced sinuses of Valsalva in bicuspid aortic valve disease. The journal of thoracic and cardiovascular surgery. 2011 Aug;142(2):278-84. PMID: 21036368. DOI: 10.1016/j.jtcvs.2010.08.055.

45. Fazel S.S., Mallidi H.R., Lee R.S., Sheehan M.P., Liang D., Fleischman D., Herfkens R., Mitchell R.S., Miller D.C.. The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. The journal of thoracic and cardiovascular surgery. 2008 Apr;135(4):901-7, 907.e1-2. PMID: 18374778. DOI: 10.1016/j.jtcvs.2008.01.022.

46. Kim D.H., Handschumacher M.D., Levine R.A., et al. Aortic valve adaptation to aortic root dilatation: insights into the mechanism of functional aortic regurgitation from 3-dimensional cardiac computed tomography. Circ Cardiovasc Imaging. 2014;7(5):828–835

47. Ballocca F., Ruggeri G.M., Roscoe A., Thampinathan B., David T.E., Lang R.M., Meineri M., Tsang W.. Aortic root changes before and after surgery for chronic aortic dilatation: A 3D Echocardiographic study. Echocardiography. 2019 Feb;36(2):376-385. PMID: 30556230. DOI: 10.1111/echo.14216

48. Ju M.H., Oh S.Y., Choo S.J., Yang D.H., Kang J-W., Kim J.B., Shinn S.H., Lee J.W., Lim T-H.. Three-Dimensional Computed Tomographic Analysis of Normal and Aneurysmal Aortic Roots: Is There a Specific Geometric Pattern in the Aortic Root? Clinical Anatomy. 2020 Jan;33(1):117-123. PMID: 31576608. DOI: 10.1002/ca.23482.

49. David T. E.. Additional anatomic information on the aortic root. The Journal of thoracic and cardiovascular surgery. 2015 Feb;149(2):408-10. PMID: 25457257. DOI: 10.1016/j.jtcvs.2014.10.014.

50. Sasaki K., Kunihara T., Kasegawa H., Seki M., Seki H., Takada J., Sasuga S., Kumazawa R., Umezu M., Iwasaki K.. Aortic root geometry following valve‐sparing root replacement with reimplantation or remodeling: experimental investigation under static continuous pressure. Journal of artificial organs. 2021 Jun;24(2):245-253. PMID: 33484362. DOI: 10.1007/s10047-020-01242-4


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Noginov V.K., Komarov R.N., Bagaturia G.O., Dzyunja A.N., Lenkovets M. SURGICAL ANATOMY OF THE AORTIC ROOT IN THE ASPECT OF ITS RECONSTRUCTION. Complex Issues of Cardiovascular Diseases. 2025;14(1):91-102. (In Russ.) https://doi.org/10.17802/2306-1278-2025-14-1-91-102

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