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Published on: May 13, 2021
Relationship between the aortic root and the atrioventricular conduction axis
Robert H Anderson1, Diane E Spicer2, Damián Sánchez-Quintana3
1Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK.
Insights
Transcatheter aortic valve replacement can damage the atrioventricular conduction axis. Understanding the aortic root
Area of Science:
- Cardiovascular anatomy
- Interventional cardiology
- Cardiac electrophysiology
Background:
- Damage to the atrioventricular conduction axis is a complication of transcatheter aortic valve prostheses implantation.
- Accurate anatomical knowledge of the conduction axis in relation to the aortic root is crucial for risk reduction.
Purpose of the Study:
- To investigate the relationship between the conduction axis and the aortic root.
- To identify anatomical variations that may increase the risk of conduction disturbances after transcatheter aortic valve implantation.
Main Methods:
- Histological examination of cardiac tissue.
- Analysis of clinical imaging to assess aortic root anatomy and rotation.
- Correlation of anatomical findings with the risk of atrioventricular conduction disturbances.
Main Results:
- A close relationship exists between the left bundle branch and the right coronary aortic leaflet in many cases.
- The extent of the inferoseptal recess and aortic root rotation are variable features.
- Counterclockwise rotation of the aortic root, as viewed by the imager, places more of the conduction axis within the outflow tract circumference and is associated with a narrower inferoseptal recess.
Conclusions:
- Variability in aortic root anatomy, including rotation and inferoseptal recess dimensions, significantly impacts the proximity of the conduction axis.
- A comprehensive understanding of these anatomical variations is essential for minimizing atrioventricular conduction problems during transcatheter aortic valve procedures.
Abstract:
Damage to the atrioventricular conduction axis continues to be a problem subsequent to transcatheter implantation of aortic valvar prostheses. Accurate knowledge of the precise relationships of the conduction axis relative to the aortic root could greatly reduce the risk of such problems. Current diagrams highlighting these relationships rightly focus on the membranous septum. The current depictions, however, overlook a potentially important relationship between the superior fascicle of the left bundle branch and the nadir of the semilunar hinge of the right coronary leaflet of the aortic valve. Recent histological investigations demonstrate, in many instances, a very close relationship between the left bundle branch and the right coronary aortic leaflet. The findings also highlight two additional variable features, which can be revealed by clinical imaging. The first of these is the extent of an inferoseptal recess of the left ventricular outflow tract. The second is the extent of rotation of the aortic root within the base of the left ventricle. Much more of the conduction axis is within the confines of the circumference of the outflow tract when the root is rotated in counterclockwise fashion as assessed from the perspective of the imager, with this finding itself associated with a much narrower inferoseptal recess. A clear understanding of the marked variability within the aortic root is key to avoiding future problems with atrioventricular conduction.
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