The Significance of the Interleaflet Triangles in Determining the Morphology of Congenitally Abnormal Aortic Valves: Implications for Noninvasive Imaging and Surgical Management

Tretter, Justin T.; Spicer, Diane E.; Mori, Shigeo; Chikkabyrappa, Sathish; Redington, Andrew N.; Anderson, Robert H.

doi:10.1016/j.echo.2016.08.017

Cited by 46 publications

(85 citation statements)

References 43 publications

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“…This latter plane, which is oval rather than circular, and which represents the so‐called echocardiographic “annulus,” has no anatomical counterpart. The sizes of the individual aortic sinuses, furthermore, are not identical (Vollebergh and Becker, ; Tretter et al ; Mori et al ). Because of this, the plane of the basal ring is rarely parallel with the plane of the sinutubular junction.…”

Section: Discussionmentioning

confidence: 99%

Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve

et al. 2018

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Knowledge of the anatomy of the membranous septum, as a surrogate to the location of the atrioventricular conduction axis, is a prerequisite for those undertaking transcatheter implantation of the aortic valve (TAVI). Equally important is its relationship of the virtual basal ring. This feature, however, has yet to be adequately described in the living heart. We analyzed computed tomographic angiographic datasets from 107 candidates (84.1 ± 5.2 years, 68% women) for TAVI. Using multiplanar reconstructions, we measured the height and width of the membranous septum, and the distances of its superior and inferior margins from the virtual basal ring plane. We also assessed the extent of wedging of the aortic root between the mitral valve and the ventricular septum. Mean heights and widths of the membranous septum were 6.6 ± 2.0, and 10.2 ± 3.1 mm, respectively, with its size significantly associated with that of the aortic root (P < 0.05). Its superior and inferior margins were 4.5 ± 2.3 and 2.1 ± 2.1 mm, respectively, from the plane of the basal ring. The inferior distance, the surrogate for the adjacency of the atrioventricular conduction axis, was ≤ 5mm in 91% of the patients. Deeper wedging of the aortic root was independently correlated with a shorter inferior distance (β = 0.0569, P = 0.0258). The membranous septum is appreciably closer to the virtual basal ring than previously appreciated. These findings impact on estimations of the risk of damage to the atrioventricular conduction axis during TAVI. Clin. Anat. 31:525-534, 2018. © 2018 Wiley Periodicals, Inc.

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Section: Discussionmentioning

confidence: 99%

Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve

et al. 2018

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“…Thus, although the anatomy has been well described in the human heart (Tretter et al. ), the embryology has remained obscure. Our clarification of the origins of these tissues may help to understand diseases of the aortic root.…”

Section: Discussionmentioning

confidence: 99%

“…Similarly, in unicuspid aortic valve, there is usually only one well‐formed interleaflet triangle (Tretter et al. ). Both bicuspid and unicuspid aortic valves are associated with aortopathy, which includes dilation of the root or ascending portions of the aorta.…”

Section: Discussionmentioning

confidence: 99%

“…It is notable that, whereas all three interleaflet triangles in the pulmonary root are supported by myocardium, this is not the case in the aortic root, where only the RDL triangle is entirely supported by the ventricular myocardium. Thus, although the anatomy has been well described in the human heart (Tretter et al 2016), the embryology has remained obscure. Our clarification of the origins of these tissues may help to understand diseases of the aortic root.…”

Section: Discussionmentioning

confidence: 99%

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Development and maturation of the fibrous components of the arterial roots in the mouse heart

et al. 2017

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The arterial roots are important transitional regions of the heart, connecting the intrapericardial components of the aortic and pulmonary trunks with their ventricular outlets. They house the arterial (semilunar) valves and, in the case of the aorta, are the points of coronary arterial attachment. Moreover, because of the semilunar attachments of the valve leaflets, the arterial roots span the anatomic ventriculo‐arterial junction. By virtue of this arrangement, the interleaflet triangles, despite being fibrous, are found on the ventricular aspect of the root and located within the left ventricular cavity. Malformations and diseases of the aortic root are common and serious. Despite the mouse being the animal model of choice for studying cardiac development, few studies have examined the structure of their arterial roots. As a consequence, our understanding of their formation and maturation is incomplete. We set out to clarify the anatomical and histological features of the mouse arterial roots, particularly focusing on their walls and the points of attachment of the valve leaflets. We then sought to determine the embryonic lineage relationships between these tissues, as a forerunner to understanding how they form and mature over time. Using histological stains and immunohistochemistry, we show that the walls of the mouse arterial roots show a gradual transition, with smooth muscle cells (SMC) forming the bulk of wall at the most distal points of attachments of the valve leaflets, while being entirely fibrous at their base. Although the interleaflet triangles lie within the ventricular chambers, we show that they are histologically indistinguishable from the arterial sinus walls until the end of gestation. Differences become apparent after birth, and are only completed by postnatal day 21. Using Cre‐lox‐based lineage tracing technology to label progenitor populations, we show that the SMC and fibrous tissue within the walls of the mature arterial roots share a common origin from the second heart field (SHF) and exclude trans‐differentiation of myocardium as a source for the interleaflet triangle fibrous tissues. Moreover, we show that the attachment points of the leaflets to the walls, like the leaflets themselves, are derived from the outflow cushions, having contributions from both SHF‐derived endothelial cells and neural crest cells. Our data thus show that the arterial roots in the mouse heart are similar to the features described in the human heart. They provide a framework for understanding complex lesions and diseases affecting the aortic root.

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“…The normal aortic root, extending from the virtual basal ring to the sinutubular junction, has its leaflets hinged from the supporting valvar sinuses in semilunar fashion, producing a crown or coronet-like configuration 5. The spaces on the ventricular aspect of the hinges are occupied by the fibrous interleaflet triangles, with the leaflets coming together distally at the sinutubular junction.…”

Section: Introductionmentioning

confidence: 99%

Variations in rotation of the aortic root and membranous septum with implications for transcatheter valve implantation

Tretter

Mori

Saremi

et al. 2017

Heart

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The Significance of the Interleaflet Triangles in Determining the Morphology of Congenitally Abnormal Aortic Valves: Implications for Noninvasive Imaging and Surgical Management

Cited by 46 publications

References 43 publications

Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve

Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve

Development and maturation of the fibrous components of the arterial roots in the mouse heart

Variations in rotation of the aortic root and membranous septum with implications for transcatheter valve implantation

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