Sinus Valsalva Sinus Valsalva asymmetry is the asymmetry is the “normal” aortic “normal” aortic root anatomyroot anatomy

Andras C. KollarAndras C. KollarUTMB, Galveston TX. USAUTMB, Galveston TX. USA

Objective and methodsObjective and methods• To obtain macroscopic tissue dimensions and To obtain macroscopic tissue dimensions and

geometry patterns of sinus wall segments in geometry patterns of sinus wall segments in fresh autopsy specimensfresh autopsy specimens

• Unselected autopsies (>18 years of age) with Unselected autopsies (>18 years of age) with no aortic valve/root pathology (n=30)no aortic valve/root pathology (n=30)

• Valve competence was tested with water Valve competence was tested with water probeprobe

• The aortic root was dissected away from the The aortic root was dissected away from the heartheart

• The coronary arteries were amputatedThe coronary arteries were amputated

Methods: the specimens were Methods: the specimens were opened at the commissure opened at the commissure between R and NC leafletsbetween R and NC leaflets

Methods: the valve leaflets Methods: the valve leaflets were excisedwere excised

Methods: the sinus wall Methods: the sinus wall segments were separated from segments were separated from

the scalloped annulusthe scalloped annulus

Methods: two radial incisions were Methods: two radial incisions were made to flatten naturally bulging made to flatten naturally bulging

sinus wall segmentssinus wall segments

Measurements: sinus length Measurements: sinus length (L), width (W) and (L), width (W) and

intercommissural distance (IC)intercommissural distance (IC)(dashed line: sinus ridge arching between (dashed line: sinus ridge arching between

commissures)commissures)

Results: average sinus Results: average sinus dimensionsdimensions

Left Sinus(n=30)

Right Sinus(n=30)

Noncoronary Sinus(n=30)

Intercomissuraldistance (mm) 21.7±3.7 23.5±4.0 23.4±3.5

Sinus width (mm) 22.7±3.5 24.2±4.0 24.4±3.9

Sinus length (mm) 20.0±3.0 21.2±3.9 21.4±4.1

Sinus surface area (calculated mm2) 362.2±102.4 413.4±137.6 420±146.7

Length/width (ratio) 0.89±0.10 0.88±0.09 0.87±0.10

STJ:BRSTJ:BR Overall OverallSpec # Spec # Age Age RatioRatio ICIC WidthWidth LengthLength Sinus SASinus SA PatternPattern11 5353 1.051.05 L<R=NCL<R=NC L<R=NCL<R=NC R=NC<LR=NC<L R<NC<LR<NC<L AsymmetricAsymmetric22 6565 1.001.00 L<R=NCL<R=NC R<L=NCR<L=NC R<L=NCR<L=NC R<L<NCR<L<NC AsymmetricAsymmetric33 4747 0.960.96 L<R=NCL<R=NC L<R=NCL<R=NC L=R<NCL=R<NC L<R<NCL<R<NC AsymmetricAsymmetric44 3030 0.900.90 R=L<NCR=L<NC L<R=NCL<R=NC L=R=NCL=R=NC L<R=NCL<R=NC AsymmetricAsymmetric55 6767 1.091.09 L=R=NCL=R=NC L=R<NCL=R<NC L<R=NCL<R=NC L<R<NCL<R<NC AsymmetricAsymmetric66 2020 0.950.95 L<R<NCL<R<NC L<R<NCL<R<NC L=NC<RL=NC<R L<NC<RL<NC<R AsymmetricAsymmetric77 4444 0.890.89 L=R<NCL=R<NC L<R<NCL<R<NC L<R<NCL<R<NC L<R<NCL<R<NC AsymmetricAsymmetric88 5353 0.960.96 L<NC<RL<NC<R L<NC<RL<NC<R L=NC<RL=NC<R L<NC<RL<NC<R AsymmetricAsymmetric99 6868 1.051.05 L<R<NCL<R<NC L<R<NCL<R<NC L=R<NCL=R<NC L<R<NCL<R<NC AsymmetricAsymmetric1010 7070 1.041.04 NC<L=RNC<L=R L=R=NCL=R=NC L<R<NCL<R<NC L<R<NCL<R<NC AsymmetricAsymmetric1111 5050 0.920.92 R<L=NCR<L=NC L=R<NCL=R<NC L=R=NCL=R=NC R<L<NCR<L<NC AsymmetricAsymmetric1212 7878 1.081.08 NC<L<RNC<L<R NC<L=RNC<L=R NC<L=RNC<L=R NC<R<LNC<R<L AsymmetricAsymmetric1313 4848 1.081.08 L<R<NCL<R<NC L=R<NCL=R<NC R<L=NCR<L=NC R<L<NCR<L<NC AsymmetricAsymmetric1414 7575 1.081.08 L<NC<RL<NC<R L<R=NCL<R=NC L<NC<RL<NC<R L<NC<RL<NC<R AsymmetricAsymmetric1515 5858 1.001.00 L=NC<RL=NC<R L=NC<RL=NC<R L=NC<RL=NC<R L=NC<RL=NC<R AsymmetricAsymmetric1616 2525 0.910.91 L=R=NCL=R=NC L=R=NCL=R=NC R<L=NCR<L=NC NC<L<RNC<L<R AsymmetricAsymmetric1717 6262 1.041.04 L<R=NCL<R=NC L<NC<RL<NC<R L<R=NCL<R=NC L<NC<RL<NC<R Asymmetric Asymmetric 1818 9696 1.351.35 L=R=NCL=R=NC L=R=NCL=R=NC L<R<NCL<R<NC L<R<NCL<R<NC AsymmetricAsymmetric1919 4444 1.001.00 L=R<NCL=R<NC L=R<NCL=R<NC L=R=NCL=R=NC L=R<NCL=R<NC AsymmetricAsymmetric2020 5353 1.001.00 L<R<NCL<R<NC L<R=NCL<R=NC L<R=NCL<R=NC L<R<NCL<R<NC AsymmetricAsymmetric2121 5555 1.101.10 NC<R=LNC<R=L NC<L=RNC<L=R NC=R<LNC=R<L NC<R<LNC<R<L AsymmetricAsymmetric2222 3535 1.001.00 NC<R=LNC<R=L R=NC<LR=NC<L L=NC<RL=NC<R NC<L<RNC<L<R AsymmetricAsymmetric2323 5959 1.191.19 L=NC<RL=NC<R L=R=NCL=R=NC L=R=NCL=R=NC L<R=NCL<R=NC AsymmetricAsymmetric2424 4343 0.910.91 L=R<NCL=R<NC L=R<NCL=R<NC L=R<NCL=R<NC R<L<NCR<L<NC AsymmetricAsymmetric2525 3737 0.910.91 L=R=NCL=R=NC L=R=NCL=R=NC L=R=NCL=R=NC L<R=NCL<R=NC SymmetricSymmetric2626 3636 0.950.95 L<R=NCL<R=NC L=NC<RL=NC<R L=R=NCL=R=NC L<NC<RL<NC<R AsymmetricAsymmetric2727 3131 0.840.84 L<R=NCL<R=NC L=R=NCL=R=NC R<L=NCR<L=NC R<L<NCR<L<NC AsymmetricAsymmetric2828 8484 1.171.17 L=NC<RL=NC<R L<NC<RL<NC<R L<R=NCL<R=NC L<NC<RL<NC<R AsymmetricAsymmetric2929 4343 0.920.92 L=R=NCL=R=NC L<R=NCL<R=NC L=R=NCL=R=NC L<R<NCL<R<NC AsymmetricAsymmetric3030 4141 0.950.95 L<R<NCL<R<NC L<R<NCL<R<NC L<R=NCL<R=NC L<R<NCL<R<NC AsymmetricAsymmetric

Summary of Sinus Wall Dimensional Relationships

(1 mm difference in direct size (1 mm difference in direct size measurements was considered insignificant)measurements was considered insignificant)

ConclusionsConclusions • The normal Valsalva sinuses The normal Valsalva sinuses

are almost always asymmetricare almost always asymmetric• Aneurysmal dilatation likely Aneurysmal dilatation likely

exaggerates the preexisting exaggerates the preexisting asymmetryasymmetry

• Based on these data a newBased on these data a newgraft design is proposed graft design is proposed for aortic root remodelingfor aortic root remodeling

““Cone” graft for aortic root Cone” graft for aortic root remodelingremodeling

• Widening provides excess material to recreate sinus bulges • The tongues are individually tailored to match asymmetry

(US patent is pending – application # 12127639)