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Aortic and vascular disease
Original research article
Variations in rotation of the aortic root and membranous septum with implications for transcatheter valve implantation
  1. Justin T Tretter1,
  2. Shumpei Mori2,
  3. Farhood Saremi3,
  4. Sathish Chikkabyrappa4,
  5. Kristen Thomas5,
  6. Fang Bu5,
  7. Rohit S Loomba1,
  8. Tarek Alsaied1,
  9. Diane E Spicer6,
  10. Robert H Anderson7
  1. 1 Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2 Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
  3. 3 Department of Radiology, University of Southern California, Los Angeles, California, USA
  4. 4 Division of Pediatric Cardiology, Seattle Children’s Hospital, University of Washington, Seattle, Washington, USA
  5. 5 Department of Pathology, New York University Langone Medical Center, New York, USA
  6. 6 Department of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA
  7. 7 Institute of Genetics, Newcastle University, Newcastle upon Tyne, UK
  1. Correspondence to Dr Justin T Tretter, The Heart Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; justin.tretter{at}cchmc.org

Abstract

Objective It is intuitive to suggest that knowledge of the variation in the anatomy of the aortic root may influence the outcomes of transcatheter implantation of the aortic valve (TAVI). We have now assessed such variation.

Methods We used 26 specimens of normal hearts and 78 CT data sets of adults with a mean age of 64±15 years to measure the dimensions of the membranous septum and to assess any influence played by rotation of the aortic root, inferring the relationship to the atrioventricular conduction axis.

Results The aortic root was positioned centrally in the majority of both cohorts, although with significant variability. For the cadaveric hearts, 14 roots were central (54%), 4 clockwise-rotated (15%) and 8 counterclockwise-rotated (31%). In the adult CT cohort, 44 were central (56%), 21 clockwise-rotated (27%) and 13 counterclockwise-rotated (17%). A mean angle of 15.5° was measured relative to the right fibrous trigone in the adult CT cohort, with a range of −32° to 44.7°. The dimensions of the membranous septum were independent of rotation. Fibrous continuity between the membranous septum and the right fibrous trigone increased with counterclockwise to clockwise rotation, implying variation in the relationship to the atrioventricular conduction axis.

Conclusions The central fibrous body is wider, providing greater fibrous support, in the setting of clockwise rotation of the aortic root. Individuals with this pattern may be more vulnerable to conduction damage following TAVI. Knowledge of such variation may prove invaluable for risk stratification.

  • transcatheter valve interventions
  • cardiac computer tomographic (ct) imaging
  • aortic stenosis
  • endovascular procedures for aortic and vascular disease

https://doi.org/10.1136/heartjnl-2017-312390

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    Footnotes

    • Contributors JTT planned the study, performed the heart specimen analysis, helped in the statistical analysis, and drafted the initial manuscript and subsequent revisions. SM helped plan the study, performed the CT analysis and related statistical analysis, and made contributions to the revisions of the manuscript. FS helped guide the CT analysis and made contributions to the revisions of the manuscript. SC helped in the heart specimen analysis and made contributions to the revisions of the manuscript. KT and FB helped in the specimen analysis. RSL made contributions to the revisions of the manuscript. TA guided the statistical analysis of the heart specimens and made contributions to the revisions of the manuscript. DES helped in the heart specimen analysis and made contributions to the revisions of the manuscript. RHA guided the study design and made final revisions to the manuscript.

    • Competing interests None declared.

    • Ethics approval The studies involved had institutional review board approval at their respective institutions.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Individual data can be shared upon request.