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Eur J Cardiothorac Surg 2006;29:1006-1007
© 2006 Elsevier Science NL
Cardiac Unit, Institute of Child Health, University College, 30 Guilford Street, London WC1N 1EH, United Kingdom
* Corresponding author. Tel.: +44 207 242 9789; fax: +44 207 831 0488. (Email: r.anderson{at}ich.ucl.ac.uk).
It was, perhaps, paradoxical that as I prepared to write this editorial comment to accompany the article describing ‘tricuspidisation’ of the bifoliate aortic valve [1], I also had at my elbow the December issue of the Journal for the year 2005. In this issue, I discovered another editorial comment, entitled ‘The aortic valve: an everlasting mystery to the surgeon’ [2]. In the light of my own comments that will follow, it is worth quoting in its entirety the opening sentence of this editorial. Manuel Antunes started his own comment by stating ‘Despite its apparent simplicity, the anatomy, physiology, and pathophysiology of the aortic valve have persistently defied the comprehension of the surgeons.’ I do not consider myself qualified to express an opinion on the reasons why understanding of the physiology and pathophysiology have defeated the combined attentions of the surgical world, but I do consider myself able to point to one of the major reasons why the anatomic arrangement continues to raise problems.
If the interested reader studies the article [3] that formed the focus of the editorial comment provided by Antunes [2], he or she will discover that Thubrikar and colleagues describe the aortic root as extending between the sinutubular junction and the ‘annulus diameter’. Although they do not specifically define the level of this ‘annulus’, it is clear that they refer to the diameter of the virtual ring constructed by joining together the most proximal attachments of the leaflets of the aortic valve within the left ventricle. Pretre and colleagues [1], however, when discussing their technique for surgical reconstruction of the aortic valve with only two leaflets, describe how they create a crown-like arrangement for the new valve, with the leaflets suspended at semilunar lines of attachment which extend proximally to the level of the sinutubular junction. Such an arrangement is intuitively optimal, since it replicates the arrangement seen in the normally trifoliate aortic valve [4]. But does it help our understanding when the group from Zurich then describe these semilunar attachments as a ‘crown-like annulus’? I cannot speak for the entirety of the surgical world in this regard, and most surgeons might well agree with Pretre and colleagues [1] in viewing the semilunar attachments of the leaflets as the ‘annulus’, but it is evident from analysis of the publication of Thubrikar and colleagues [3] that the group from Charlotte do not share this opinion. And the level of the aortic root chosen by Thubrikar and colleagues for definition as the ‘annulus’ does at least take the form of a ring!
When I reviewed the publication of Pretre and colleagues [1] subsequent to it submission to the Journal, I suggested that they could avoid considerable potential misunderstanding if, instead of describing the unequivocal crown-like arrangement they create with their surgical technique as an ‘annulus’, they simply alluded to the shape of the hingelines of their newly created aortic valve. As is their privilege, they chose to ignore my comments. In the light of their response, nonetheless, it comes as no surprise to me that Antunes [2] should need to emphasise the ongoing mystery of the aortic valve. In my opinion, such mystery will only be removed when surgeons, and those investigating the aortic root, use words in their vernacular meaning for the purposes of description, rather that attributing to these words meanings which are totally foreign to anyone who has pre-existing linguistic skills. Thus, an ‘annulus’ is no more than a little anus, and the word should convey the meaning of a ring. A crown, of course, is shaped in the form of a ring, but the phrase ‘crown-shaped ring’ is surely a tautology, since ‘crown-shaped’ is more than adequate in its own right, and certainly less confusing. In the long term, it can only be the usage that will dictate the most appropriate words to be used for description of the aortic root. If we are to satisfy Antunes [2], however, and demystify our understanding of the anatomy of the aortic valve, it would be advantageous to place a moratorium on the use of ‘annulus’ to describe any part of this anatomy, or else convene a group to determine which part of the valve is best defined in this fashion. As Antunes [2] concluded in his own editorial, if we are to make progress in surgical science, it may be necessary to challenge time-honoured conventions.
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This article has been cited by other articles:
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  N. Piazza, P. de Jaegere, C. Schultz, A. E. Becker, P. W. Serruys, and R. H. Anderson Anatomy of the Aortic Valvar Complex and Its Implications for Transcatheter Implantation of the Aortic Valve Circ Cardiovasc Intervent, August 1, 2008; 1(1): 74 - 81. [Abstract] [Full Text] [PDF]
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 J. Dhareshwar, D. V. Miller, and T. M. Sundt III Reply to the editor. J. Thorac. Cardiovasc. Surg., June 1, 2008; 135(6): 1402 - 1404. [Full Text] [PDF]
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