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Multimodality Imaging of the Anatomy of the Aortic Root Journal of Cardiovascular Development and Disease Systematic Review Multimodality Imaging of the Anatomy of the Aortic Root Vera Lucia Paiocchi 1, Francesco F. Faletra 1,*, Enrico Ferrari 1, Susanne Anna Schlossbauer 1, Laura Anna Leo 1 and Francesco Maisano 2 1 Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland; [email protected] (V.L.P.); [email protected] (E.F.); [email protected] (S.A.S.); [email protected] (L.A.L.) 2 Cardiac Surgery, Università Vita Salute San Raffaele, via Olgettina 58, 20132 Milano, Italy; [email protected] * Correspondence: [email protected]; Tel.: +41-91-805-3179; Fax: +41-91-805-3167 Abstract: The aortic root has long been considered an inert unidirectional conduit between the left ventricle and the ascending aorta. In the classical definition, the aortic valve leaflets (similar to what is perceived for the atrioventricular valves) have also been considered inactive structures, and their motion was thought to be entirely passive—just driven by the fluctuations of ventricular–aortic gradients. It was not until the advent of aortic valve–sparing surgery and of transcatheter aortic valve implantation that the interest on the anatomy of the aortic root again took momentum. These new procedures require a systematic and thorough analysis of the fine anatomical details of the components of the so-called aortic valve apparatus. Although holding and dissecting cadaveric heart specimens remains an excellent method to appreciate the complex “three-dimensional” nature of the aortic root, nowadays, echocardiography, computed tomography, and cardiac magnetic resonance provide excellent images of cardiac anatomy both in two- and three-dimensional format. Indeed, Citation: Paiocchi, V.L.; Faletra, F.F.; modern imaging techniques depict the aortic root as it is properly situated within the thorax in an Ferrari, E.; Schlossbauer, S.A.; Leo, attitudinally correct cardiac orientation, showing a sort of “dynamic anatomy”, which admirably L.A.; Maisano, F. Multimodality joins structure and function. Finally, they are extensively used before, during, and after percutaneous Imaging of the Anatomy of the Aortic structural heart disease interventions. This review focuses on the anatomy of the aortic root as Root. J. Cardiovasc. Dev. Dis. 2021, 8, revealed by non-invasive imaging techniques. 51. https://doi.org/10.3390/ jcdd8050051 Keywords: aortic root; echocardiography; computed tomography (CT); cardiac magnetic resonance Academic Editor: Nina (CMR) Ajmone Marsan Received: 24 March 2021 Accepted: 1 May 2021 1. Introduction Published: 4 May 2021 Cardiac anatomy is usually taught to medical students on the basis of examination of the cadaveric heart specimens. Indeed, holding and dissecting a human heart remains Publisher’s Note: MDPI stays neutral an excellent method to appreciate the complex “three-dimensional” anatomy of the heart. with regard to jurisdictional claims in However, it must be recognized that cardiac anatomy is, “per se”, extremely complex and published maps and institutional affil- not always does it become part of the student’s cultural background, especially when it is iations. learned in the first years of medical school as a small part of the body’s anatomy. In addition, anatomical exploration is done in the flaccid, cadaveric heart. Today, echocardiography, computed tomography (CT), and cardiac magnetic resonance (CMR) provide excellent images of cardiac anatomy both in two- and three-dimensional format. Although these Copyright: © 2021 by the authors. techniques are mainly used to discover pathological features, they also offer exceptional Licensee MDPI, Basel, Switzerland. images of normal cardiac anatomy. For many aspects, these techniques can be considered This article is an open access article nowadays as a kind of novel “anatomical gold standard” for the following reasons: First, distributed under the terms and differently from explanted hearts, these techniques depict the cardiac anatomy as it is conditions of the Creative Commons properly situated within the thorax in an attitudinally correct cardiac orientation. Second, Attribution (CC BY) license (https:// they have the unique ability to show “live” images from the beating heart, a sort of creativecommons.org/licenses/by/ “dynamic anatomy”, which admirably joins structure and function. Third, the rapid 4.0/). J. Cardiovasc. Dev. Dis. 2021, 8, 51. https://doi.org/10.3390/jcdd8050051 https://www.mdpi.com/journal/jcdd J. Cardiovasc. Dev. Dis. 2021, 8, x FOR PEER REVIEW 2 of 20 J. Cardiovasc. Dev. Dis. 2021, 8, x FOR PEER REVIEW 2 of 20 J. Cardiovasc. Dev. Dis. 2021, 8, 51 2 of 18 progression of percutaneous structural heart disease interventions highlights the need to progression of percutaneous structural heart disease interventions highlights the need to revisit cardiac anatomy using a multimodality approach. These non-invasive techniques revisitprogression cardiac ofanatomy percutaneous using a structural multimodality heart diseaseapproach. interventions These non-invasive highlights techniques the need to have reached an optimal agreement with anatomy. Indeed, their accuracy in providing haverevisit reached cardiac an anatomy optimal usingagreement a multimodality with anatomy. approach. Indeed, These their non-invasiveaccuracy in providing techniques fine anatomic details has been verified in several studies by comparing side-by-side ana- finehave anatomic reached details an optimal has been agreement verified with in several anatomy. studies Indeed, by theircomparing accuracy side-by-side in providing ana- fine tomic specimens and non-invasive images [1–9]. This review focuses on the anatomy of tomicanatomic specimens details and has non-invasive been verified images in several [1–9 studies]. This byreview comparing focuses side-by-side on the anatomy anatomic of the aortic root as revealed by non-invasive imaging techniques. thespecimens aortic root and as non-invasiverevealed by non-invasive images [1–9]. imaging This review techniques. focuses on the anatomy of the aortic root as revealed by non-invasive imaging techniques. 2. Aortic Root 2. Aortic Root 2. AorticThe fine Root details of the “aortic root complex” have been often overlooked by the car- The fine details of the “aortic root complex” have been often overlooked by the car- diologyThe community. fine details Two of the main “aortic reasons root complex”explain this have sort been of “disinterestedness” often overlooked by towards the cardi- diology community. Two main reasons explain this sort of “disinterestedness” towards thisology complex community. structure: Two (a) main for reasonsa long time, explain the thisaortic sort root of“disinterestedness” has been considered towards a simple this this complex structure: (a) for a long time, the aortic root has been considered a simple andcomplex inert unidirectional structure: (a) for conduit a long between time, the the aortic left root ventricle has been (LV) considered and the ascending a simple and aorta; inert and inert unidirectional conduit between the left ventricle (LV) and the ascending aorta; (b)unidirectional because aortic conduit leaflets between do not have the left an ventricleextensive (LV) attachment and the ascendingwith the ventricular aorta; (b) because myo- (b) because aortic leaflets do not have an extensive attachment with the ventricular myo- cardium,aortic leaflets their motion do not havewas thought an extensive to be attachment entirely passive—just with the ventricular driven by myocardium, fluctuations their of cardium, their motion was thought to be entirely passive—just driven by fluctuations of LV–AOmotion gradients. was thought The to advent be entirely of aortic passive—just valve–sparing driven bysurgery fluctuations and transcatheter of LV–AO gradients. aortic LV–AO gradients. The advent of aortic valve–sparing surgery and transcatheter aortic valveThe implantation advent of aortic (TAVI) valve–sparing techniques surgery renewed and the transcatheter interest on the aortic anatomy valve of implantation the aortic valve implantation (TAVI) techniques renewed the interest on the anatomy of the aortic root,(TAVI) since techniques both procedures renewed require the interest a systemat on theic anatomy and thorough of the aorticanalysis root, of sincethe fine both ana- pro- root, since both procedures require a systematic and thorough analysis of the fine ana- tomicalcedures details require of the a systematic components and of thorough this valve analysis apparatus of the[10,11]. fine anatomical details of the tomicalcomponents details of of this the valvecomponents apparatus of this [10 ,valve11]. apparatus [10,11]. 3. Terminology 3.3. Terminology Terminology There is a remarkable variability in the terms used to describe the aortic root compo- ThereThere is isa aremarkable remarkable variability variability in in the the te termsrms used used to to describe describe the the aortic aortic root root compo- compo- nents. Table 1 clarifies the terminology for everyday use. nents.nents. Table Table 11 clarifies clarifies the the te terminologyrminology for for everyday everyday use. use. Table 1. Terms used to describe the aortic root components. TableTable 1. Terms 1. Terms used usedto describe to describe the aortic the aortic root rootcomponents. components. Name Meaning NameName Meaning Meaning The term ventricular–arterialThe term ventricular–arterial
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