Impact of aortic annular geometry on aortic valve insufficiency: Insights from a preclinical, ex vivo, porcine model

Objectives: We sought to create a model of aortic insufficiency in a left heart simulator combined with 3-dimensional echocardiography and finite element modeling of the aortic valve. We examined the effects of aortic root geometry alteration on aortic insufficiency. Methods: Porcine aortic roots were analyzed on a left heart simulator before (control, n = 8) and after intervention (n = 8). Intervention entailed 3 vertical incisions at the sinotubular junction with diamond-shaped patches incorporated into the defects to increase the sinotubular junction diameter. Hemodynamic parameters were assessed, including regurgitant volume and fraction. Video and echocardiography images evaluated aortic valve function, coaptation surface area, aortic insufficiency, and effective regurgitant orifice area. Finite element modeling corroborated relationships between root geometry and aortic insufficiency, and examined cusp stress. Results: The intervention resulted in a sinotubular junction diameter increase of 55% +/- 4%. The sinotubular junction to ventriculo-aortic junction diameter ratio was significantly higher in the intervention group (1.89 +/- 0.16 vs 1.47 +/- 0.04, P = .02). Increased sinotubular junction diameter resulted in aortic insufficiency assessed by regurgitant volume (28 +/- 7 mL vs 5 +/- 2 mL, P = 3.004), regurgitant fraction (36% +/- 5% vs 7% +/- 1%, P < . 001), and effective regurgitant orifice (15 +/- 5 mm 2 vs 0 mm(2), P = .016). Intervention coaptation surface area was smaller (1.03 +/- 0.11 cm(2) vs 1.80 +/- 0.08 cm(2), P < .001). There was a linear correlation between increased sinotubular junction/ventriculo-aortic junction ratio and regurgitant fraction (R-2 = 0.65, P = .003). The finite element modeling demonstrated a similar relationship between increasing sinotubular junction diameter and aortic insufficiency severity, and between end-diastolic cusp stresses and sinotubular junction diameters (R-2 = 0.98, P < .001). Conclusions: In this model, increasing sinotubular junction diameter is linearly related to reduced coaptation surface area and increasing aortic insufficiency severity. This model provides new insights into aortic insufficiency mechanisms and may be used to evaluate novel interventions for aortic valve repair.