Valve-sparing reconstructive surgery for aortic regurgitation and/or aortic aneurysm requires detailed assessment of the aortic valve (AV) and aortic root anatomy. In this review, the authors provide recommendations for the use of three-dimensional (3D) echocardiography for AV and aortic root anatomy and function in that context. The following are key points to remember:

1. Anatomy of the AV and aortic root complex. The authors describe the anatomy of the AV and aortic root complex.
   • The aortic root encompasses the aortic cusps and extends cranially to the sinotubular junction. Caudally, the aortic root extends to the virtual circle or ellipse defined by the plane of the nadir of the cusp insertion arcs, for which the authors prefer the term 'basal ring' rather than 'aortic annulus.'
   • The normal AV has three cusps of similar dimensions, and three commissures.
   • The authors define the effective height of the cusps as the linear distance between the basal ring and the free margin of each cusp during diastole. The geometric height is defined as the curved length during diastole from the nadir of each cusp as it intersects the basal ring and the central part of the free margin.

2. Echocardiographic assessment. Two-dimensional (2D) echocardiography (whether transthoracic [TTE] or transesophageal [TEE]) usually is limited to long-axis and short-axis interrogation of the AV and aortic root; the potential for oblique imaging affects the accuracy of 2D echocardiography. In contrast, 3D TTE and 3D TEE allow image manipulation for precise assessment of the AV and aortic root anatomy.

3. Assessment of AV abnormalities. The assessment of AV anatomy abnormalities has implications for AV-sparing surgery.
   • Morphologic abnormalities of the cusps should be assessed, including calcification, tethering, prolapse, billowing due to redundant tissue, fenestrations, and flail.
   • The commissures should be assessed for commissural attachment, alignment, and fusion.
   • A bicuspid valve should be assessed for number of leaflets, complete or incomplete commissural fusion, and the circumferential orientation of the commissures.

4. Assessment of aortic regurgitation.
   • The mechanism(s) of aortic regurgitation should be assessed, including abnormalities of the AV, the aortic root, or both.
   • The severity of aortic regurgitation should be assessed using quantitative (regurgitant volume) and semi-quantitative parameters (effective regurgitant orifice area).

5. Assessment of AV repairability and the results of AV repair. For purposes of assessing the repairability of the AV, the AV morphology and aortic root dimensions should be assessed; along with aortic regurgitation jet eccentricity; and the bellies, free margins, and coaptation of all cusps.

6. Authors' recommendations. The authors make the following specific recommendations:
   • The AV effective height, geometric height, and coaptation lengths should be measured in end-diastole. All other measurements should be made in mid-systole.
   • In contrast to existing echocardiographic guidelines, the aortic root should be measured from inner edge to inner edge.
   • 3D echocardiography (TTE and/or TEE) should be used for the assessment of the AV and aortic root.

Keywords: Aortic Aneurysm, Aortic Valve Insufficiency, Cardiac Surgical Procedures, Diagnostic Imaging, Diastole, Echocardiography, Echocardiography, Three-Dimensional, Echocardiography, Transesophageal, Heart Valve Diseases, Prolapse, Systole

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