Functional and Morphological Interplay of the Aortic Valve, the Aortic Root, and the Left Ventricle

  • Marie-Annick Clavel
  • Philippe PibarotEmail author


Although often considered as separate entities, the left ventricle, the aortic valve, and the aorta have tight anatomical and functional interrelations that are essential to ensure adequate cardiac output and arterial pressures, which, in turn, are key for optimal organ perfusion. The size and elastic properties of the aorta may influence the aortic valve hemodynamics and the left ventricular (LV) hemodynamic burden and function. And vice versa, the state of LV myocardial function as well as the size and shape of the LV outflow tract and the morphology and function of the aortic valve may alter the cardiac outflow, the morphology of the aorta, and the arterial hemodynamics. These interactions between the left ventricle, aortic valve, and aorta have important implications with regard to the diagnosis and treatment of cardiovascular diseases and especially aortic valve diseases.


Aortic valve Aortic root Left ventricle Coupling 


  1. 1.
    Piazza N, de Jaegere P, Schultz C, Becker AE, Serruys PW, Anderson RH. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. J Am Heart Assoc. 2008;1:74–81.Google Scholar
  2. 2.
    Anderson RH. Clinical anatomy of the aortic root. Heart. 2000;84:670–3.CrossRefGoogle Scholar
  3. 3.
    Basso C, Boschello M, Perrone C, Mecenero A, Cera A, Bicego D, Thiene G, De DE. An echocardiographic survey of primary school children for bicuspid aortic valve. Am J Cardiol. 2004;93:661–3.CrossRefGoogle Scholar
  4. 4.
    Michelena HI, Khanna AD, Mahoney D, Margaryan E, Topilsky Y, Suri RM, Eidem B, Edwards WD, Sundt TM III, Enriquez-Sarano M. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA. 2011;306:1104–12.CrossRefGoogle Scholar
  5. 5.
    Lindman BR, Clavel MA, Mathieu P, Iung B, Lancellotti P, Otto CM, Pibarot P. Calcific aortic stenosis. Nat Rev Dis Primers. 2016;2:1–28.Google Scholar
  6. 6.
    Michelena HI, Prakash SK, Della Corte A, Bissell M, Anavekar N, Mathieu P, Bossé Y, Limongelli G, Bossone E, Windrow Benson D, Lancellotti P, Isselbacher EM, Enriquez-Sarano M, Sundt TM III, Pibarot P, Evangelista A, Milewicz DM, Body SC. Bicuspid aortic valve: identifying knowledge gaps and rising to the challenge from the international bicuspid aortic valve consortium (bavcon). Circulation. 2014;129:2691–704.CrossRefGoogle Scholar
  7. 7.
    Verma S, Siu SC. Aortic dilatation in patients with bicuspid aortic valve. N Engl J Med. 2014;370:1920–9.CrossRefGoogle Scholar
  8. 8.
    Mathieu P, Bossé Y, Huggins GS, Della Corte A, Pibarot P, Michelena HI, Limongelli G, Boulanger MC, Evangelista A, Bédard É, Citro R, Body SC, Nemer M, Schoen FJ. The pathology and pathobiology of bicuspid aortic valves: state of the art and novel research perspective. J Pathol Clin Res. 2015;1:195–206.CrossRefGoogle Scholar
  9. 9.
    Bissell MM, Hess AT, Biasiolli L, Glaze SJ, Loudon M, Pitcher A, Davis A, Prendergast B, Markl M, Barker AJ, Neubauer S, Myerson SG. Aortic dilation in bicuspid aortic valve disease: flow pattern is a major contributor and differs with valve fusion type. Circ Cardiovasc Imaging. 2013;6:499–507.CrossRefGoogle Scholar
  10. 10.
    Suga H. Time course of left ventricular pressure-volume relationship under various end diastolic volume. Jpn Heart J. 1969;10:509–15.CrossRefGoogle Scholar
  11. 11.
    Briand M, Dumesnil JG, Kadem L, Tongue AG, Rieu R, Garcia D, Pibarot P. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: Implications for diagnosis and treatment. J Am Coll Cardiol. 2005;46:291–8.CrossRefGoogle Scholar
  12. 12.
    Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol. 2009;54:1003–11.CrossRefGoogle Scholar
  13. 13.
    Harada K, Saitoh T, Tanaka J, Shibayama K, Berdejo J, Shiota T. Valvuloarterial impedance (zva), but not aortic stenosis severity, predicts syncope in aortic stenosis. Circ Cardiovasc Imaging. 2013;6:1024–31.CrossRefGoogle Scholar
  14. 14.
    Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low flow, low gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation. 2007;115:2856–64.CrossRefGoogle Scholar
  15. 15.
    Dayan V, Vignolo G, Magne J, Clavel MA, Mohty D, Pibarot P. Outcome and impact of aortic valve replacement in patients with preserved lv ejection fraction and low gradient aortic stenosis: a meta-analysis. J Am Coll Cardiol. 2015;66:2594–603.CrossRefGoogle Scholar
  16. 16.
    Devlin WH, Petrusha J, Briesmiester K, Montgomery D, Starling MR. Impact of vascular adaptation to chronic aortic regurgitation on left ventricular performance. Circulation. 1999;99:1027–33.CrossRefGoogle Scholar
  17. 17.
    Kadem L, Rieu R, Dumesnil JG, Durand LG, Pibarot P. Flow-dependent changes in Doppler-derived aortic valve effective orifice area are real and not due to artifact. J Am Coll Cardiol. 2006;47:131–7.CrossRefGoogle Scholar
  18. 18.
    Gilon D, Cape EG, Handschumacher MD, Song JK, Solheim J, VanAuker M, King MEE, Levine RA. Effect of three-dimensional valve shape on the hemodynamics of aortic stenosis: three-dimensional echocardiograpic stereolithography and patient studies. J Am Coll Cardiol. 2002;40:1479–86.CrossRefGoogle Scholar
  19. 19.
    Weyman AE, Scherrer-Crosbie M. Aortic stenosis: physics and physiology--what do the numbers really mean? Rev Cardiovasc Med. 2005;6:23–32.PubMedGoogle Scholar
  20. 20.
    Garcia D, Kadem L. What do you mean by aortic valve area: geometric orifice area, effective orifice area, or gorlin area? J Heart Valve Dis. 2006;15:601–8.PubMedGoogle Scholar
  21. 21.
    Garcia D, Pibarot P, Dumesnil JG, Sakr F, Durand LG. Assessment of aortic valve stenosis severity: a new index based on the energy loss concept. Circulation. 2000;101:765–71.CrossRefGoogle Scholar
  22. 22.
    Baumgartner H, Steffenelli T, Niederberger J, Schima H, Maurer G. “Overestimation” of catheter gradients by Doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery. J Am Coll Cardiol. 1999;33:1655–61.CrossRefGoogle Scholar
  23. 23.
    Garcia D, Dumesnil JG, Durand LG, Kadem L, Pibarot P. Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon: practical implications with regard to quantification of aortic stenosis severity. J Am Coll Cardiol. 2003;41:435–42.CrossRefGoogle Scholar
  24. 24.
    Gjertsson P, Caidahl K, Svensson G, Wallentin I, Bech-Hanssen O. Important pressure recovery in patients with aortic stenosis and high Doppler gradients. Am J Cardiol. 2001;88:139–44.CrossRefGoogle Scholar
  25. 25.
    Bahlmann E, Gerdts E, Cramariuc D, Gohlke-Baerwolf C, Nienaber CA, Wachtell K, Seifert R, Chambers JB, Kuck KH, Ray S. Prognostic value of energy loss index in asymptomatic aortic stenosis. Circulation. 2013;127:1149–56.CrossRefGoogle Scholar
  26. 26.
    Kadem L, Dumesnil JG, Rieu R, Durand LG, Garcia D, Pibarot P. Impact of systemic hypertension on the assessment of aortic stenosis. Heart. 2005;91:354–61.CrossRefGoogle Scholar
  27. 27.
    Little SH, Chan KL, Burwash IG. Impact of blood pressure on the doppler echocardiographic assessment of aortic stenosis severity. Heart. 2007;93:848–55.CrossRefGoogle Scholar
  28. 28.
    Eleid MF, Nishimura RA, Sorajja P, Borlaug BA. Systemic hypertension in low gradient severe aortic stenosis with preserved ejection fraction. Circulation. 2013;128:1349–53.CrossRefGoogle Scholar
  29. 29.
    Pibarot P, Dumesnil JG. Improving assessment of aortic stenosis. J Am Coll Cardiol. 2012;60:169–80.CrossRefGoogle Scholar
  30. 30.
    Kadem L, Garcia D, Durand LG, Rieu R, Dumesnil JG, Pibarot P. Value and limitations of the peak-to-peak gradient for the evaluation of aortic stenosis. J Heart Valve Dis. 2006;15:609–16.PubMedGoogle Scholar
  31. 31.
    Clavel MA, Messika-Zeitoun D, Pibarot P, Aggarwal S, Malouf J, Araoz P, Michelena H, Cueff C, Larose É, Capoulade R, Vahanian A, Enriquez-Sarano M. The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined doppler-echocardiographic and computed tomographic study. J Am Coll Cardiol. 2013;62:2329–38.CrossRefGoogle Scholar
  32. 32.
    le Polain de Waroux JB, Pouleur AC, Goffinet C, Vancraeynest D, Van Dyck M, Robert A, Gerber BL, Pasquet A, El Khoury G, Vanoverschelde JL. Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography. Circulation. 2007;116:I264–9.CrossRefGoogle Scholar
  33. 33.
    Rieck AE, Cramariuc D, Boman K, Gohlke-Barwolf C, Staal EM, Lonnebakken MT, Rossebo AB, Gerdts E. Hypertension in aortic stenosis: implications for left ventricular structure and cardiovascular events. Hypertension. 2012;60:90–7.CrossRefGoogle Scholar
  34. 34.
    Tastet L, Capoulade R, Clavel MA, Larose É, Shen M, Dahou A, Arsenault M, Mathieu P, Bédard É, Dumesnil JG, Tremblay A, Bossé Y, Després JP, Pibarot P. Systolic hypertension and progression of aortic valve calcification in patients with aortic stenosis: results from the PROGRESSA study. Eur Heart J Cardiovasc Imaging. 2016;18:70–8.CrossRefGoogle Scholar
  35. 35.
    Antonini-Canterin F, Huang G, Cervesato E, Faggiano P, Pavan D, Piazza R, Nicolosi GL. Symptomatic aortic stenosis: does systemic hypertension play an additional role? Hypertension. 2003;41:1268–72.CrossRefGoogle Scholar
  36. 36.
    Capoulade R, Clavel MA, Mathieu P, Côté N, Dumesnil JG, Arsenault M, Bédard E, Pibarot P. Impact of hypertension and renin-angiotensin system inhibitors in aortic stenosis. Eur J Clin Investig. 2013;43:1262–72.CrossRefGoogle Scholar
  37. 37.
    Migliore RA, Adaniya ME, Barranco M, Dorsch J, Miramont G, Gonzalez S, Tamagusuku H. Ventricular-arterial coupling in severe aortic stenosis: relation with symptoms and heart failure. Revista Argentina de Cardiologia. 2016;84:304–9.Google Scholar
  38. 38.
    Pibarot P. Ventriculo-arterial decoupling in aortic stenosis: when the ventricle and the arteries do not dance on the same tempo. Revista Argentina de Cardiologia. 2016;84:295–7.Google Scholar
  39. 39.
    Pibarot P, Dumesnil JG. Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. J Am Coll Cardiol. 2012;60:1845–53.CrossRefGoogle Scholar
  40. 40.
    Clavel MA, Magne J, Pibarot P. Low-gradient aortic stenosis. Eur Heart J. 2016;37:2645–57.CrossRefGoogle Scholar
  41. 41.
    Boodhwani M, de Kerchove L, Glineur D, Poncelet A, Rubay J, Astarci P, Verhelst R, Noirhomme P, El Khoury G. Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg. 2009;137:286–94.CrossRefGoogle Scholar

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© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Département de MédecineUniversité LavalQCCanada
  2. 2.Canada Research Chair in Valvular Heart DiseasesInstitut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Heart and Lung InstituteQCCanada

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