**8. Conclusion**

Real-Time 3D can be realized by obtaining a TEE 2D image of the aortic valve at either the 60º midesophageal, short-axis view or the 120º midesophageal, long-axis view. After the 2D image is optimized, narrow-angled acquisitions can be used to optimize the 3D image and to examine aortic valve and root anatomy. After acquisition, the aortic valve should be ori‐ ented with the right coronary cusp located inferiorly, regardless of whether the aortic or the

Color Doppler 3D TEE imaging should also be performed to detect the initial appearance of

The aortic root is a complex structure that requires analysis part by part but always remem‐ bering that all the parts contribute to form one functional unit, a three-dimensional structure

The aortic valve, like the pulmonary valve, has no tensor apparatus (i.e., chordae tendineae or papillary muscles). The commissures form tall, peaked spaces between the attachments of adjacent leaflets and attain the level of the aortic sinotubular junction, the ridge that sepa‐ rates the sinus and tubular portions of the ascending aorta. The functional aortic valve ori‐

The three half moon-shaped leaflets form pocket-like tissue flaps that are avascular. Just be‐ low the free edge of each leaflet is a ridgelike closing edge. At the center of each leaflet, the closing edge meets the free edge and forms the nodule of Arantius. Between the free and closing edges, to each side of the nodule are two crescent-shaped areas known as the lunu‐ lae, which represent the sites of leaflet apposition during valve closure. Lunular fenestra‐ tions, near the commissures are common and increase in size and incidence with age. [43] However, owing to their position distal to the closing edge, they rarely produce valvular in‐ competence. [42] When viewed from above, the linear distance along the closing edge of a leaflet is much greater than the straight-line distance between its two commissures. This ex‐ tra length of leaflet tissue is necessary for nonstenotic opening and nonregurgitant closure of the valve. [6] Normally, the diameter of the aortic annulus at the hinge points of the aortic valve is about equal to the diameter of the ascending aorta at the sinotubular junction. [44] When the valve opens, the leaflets fall back into their sinuses without the potential of oc‐ cluding any coronary orifice. The semilunar hingelines of adjacent leaflets meet at the level of the sinotubular junction, forming the commissures. The body of the leaflets are pliable

The commissure between the right and posterior aortic leaflets overlies the membranous septum and contacts the commissure between the anterior and septal leaflets of the tricuspid valve. The commissure between the right and left aortic leaflets contacts its corresponding pulmonary commissure and overlies the infundibular septum. The intervalvular fibrosa, at the commissure between the left and posterior aortic cusps, fuses the aortic valve to the an‐

left ventricular outflow tract perspective is presented.

adjoining distally to the aorta and proximally to the ventricle.

fice can be at the sinotubular junction or proximal to it. [42]

and thin in the young, although its thickness is not uniform.

flow at the onset of systole. [41]

50 Calcific Aortic Valve Disease

**7. Functional anatomy**

terior mitral leaflet. [6, 42]

In the new era of cardiac surgery, now more then ever, the need to further study the aortic valve complex anatomy and function is greater.

A thorough knowledge of the anatomy of the aortic valve and its relationships is essen‐ tial to understanding aortic valve pathology and many congenital cardiac malforma‐ tions. Also it is crucial for the diagnosis and treatment (both surgical and conservatory) of aortic valve pathology.

Accurate understanding of the anatomy of interest is of cardinal importance for the develop‐ ment of devices and treatment protocols. We emphasize the importance of considering ana‐ tomic variations in the development of treatments, an understanding of the intraindividual and interindividual variations that may exist can lead to refinements in current designs of valvular prostheses.

Although the aortic valve is the most intensely studied cardiac valve, there is still no consen‐ sus on how to describe its components and a universal terminology is yet to be found. The multidisciplinary approach will continue to be crucial in working through these challenges.
