Original article
The forgotten interleaflet triangles: A review of the surgical anatomy of the aortic valve

https://doi.org/10.1016/0003-4975(94)00893-CGet rights and content

Surgical descriptions of the aortic root are not always in keeping with anatomy as observed in the autopsied heart. Although all surgeons appreciate that the concept of the aortic annulus does not imply the presence of a straight ring as a hinge point, the nature of the supporting fibrous structures relative to the semilunar attachment of the leaflets has yet to be clarified. We have analyzed 50 normal aortic roots, two fetal aortic roots sectioned histologically in horizontal and sagittal planes, respectively, and two autopsied adult hearts in which prosthetic aortic valves had been inserted during life. Our results demonstrate the important interrelationships between aortic sinuses, valvar leaflets, and supporting left ventricular structures that produce the three fibrous interleaflet triangles. It is the structure and location of these triangles that is the key to the understanding of the surgical anatomy. Our results also show that the presently used definition of commissure does not reflect adequately the extent of the zones of apposition between adjacent valvar leaflets, essential for normal function when the valve is closed.

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    Citation Excerpt :

    Atrio-ventricular (AV) conduction disturbances generally originate in a triangular area bounded posteriorly by the anterior attachment of the non-coronary cusp (NCC), anteriorly by the posterior margin of the right coronary cusp (RCC) and inferiorly by the junction of the membranous and muscular portions of the interventricular septum [14–16]. Consequently, it must be expected that AVR with stented valve prostheses and a standard implantation technique can impair the AV conduction bundles by either direct trauma or mechanical stress to the His bundle at the region of the membranous septum and the right trigone beneath the NCC and RCC during valve excision and decalcification, or when interrupted vertical pledget-enforced mattress sutures are placed through the aortic annulus [3,5–7,9,14,15]. The occurrence of new-onset conduction abnormalities following AVR must be assumed to be causally linked to the surgical procedure, particularly in the absence of pre-existing conduction disturbances.

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1

During the course of this investigation, Dr John P. Sutton was a visiting fellow from the Medical University of South Carolina.

2

Doctors Siew Y. Ho and Robert H. Anderson are supported by the British Heart Foundation.

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