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The Annals of Thoracic Surgery, Vol 52, 640-646, Copyright © 1991 by The Society of Thoracic Surgeons
RH Anderson, WA Devine, SY Ho, A Smith and R McKay
Surgical repair of the small aortic root is limited in part by the very
structure of the outflow tract from the left ventricle. The root is not
constructed on the basis of a ringlike annulus supporting the leaflets of
the aortic valve. The only truly circular structure within the outflow
tract is the junction of the aortic wall with the underlying ventricular
structures, themselves partly muscular and partly fibrous. This circular
ventriculoarterial junction is crossed by the semilunar attachments of the
leaflets of the aortic valve, producing an interlinking arrangement between
the expanded aortic sinuses and three triangles of fibrous tissue placed
beneath the apexes of the commissures between the valve leaflets. The
triangles form extensions of the left ventricle that are related, in part,
to the pericardial cavity surrounding the heart. The arrangements of the
attachment of the leaflets in malformed valves with two (or only one)
effective leaflets are highly abnormal, although these valves are usually
produced on the template of three aortic sinuses. The valve with two
leaflets rarely gives problems during childhood. In valves producing
"critical stenosis", there is usually only one effective leaflet, a
condition due to incomplete liberation of two of the anticipated three
commissures. Detailed study shows that, in these malformed hearts, the
attachment of the leaflets is much more annular than in normal valves, with
inadequate formation of the fibrous triangles.
ARTICLES
The myth of the aortic annulus: the anatomy of the subaortic outflow tract
Department of Paediatrics, National Heart and Lung Institute, London, United Kingdom.
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