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TECHNICAL NOTE

THE GEOMETRY OF THE AORTIC ROOT IN HEALTH, AT VALVE

DISEASE AND AFTER VALVE REPLACEMENT

H. REUL. A. VAHLBRUCH. M. GIERSIEPEN, TH. SCHMITZ-RODE, V. HIRTZ and S. EFFERT*

Helmholtz Institute for Biomedical Engineering and *Medical Clinic I at the RWTH Aachen.
Pauwelsstrasse 30, D-5100 Aachen. F.R.G.

Abstract-For the design of aortic valve prostheseswith a separation-free Row field and minimum pressure
drop the geometry of the aortic root is of high importance. since an appropriate adjustment of the prostheses
to the surrounding geometry could largely reduce the risk of thromboembolic complications. For the
investigation of the geometry of the aortic root 604 angiographic films out of a total stock of 15,000 of the
Medical Clinic I were evaluated. The film material was preclassifiedinto five clinical categories according to
the patients data. For each category characteristic geometries could be derived in non-dimensional form.

I. INTRODUCTION 3. METHOD

The geometry of the aortic root is of prime importance for the
aoorooriate internal flow field (Bellhouse and Talbot, 1969;
SGan;on and Clark. 1974; Muller et al.. 1975; Swanson;
1975; Reul and Talukder, 1979). Through vortex formation
within the aortic sinus the opening and closing motion of the
valve is supported on one hand and. on the other hand, the
sinus vortex during the closed state of the valve provides a
good washout of the sinus cavity, thus preventing thrombotic
depositions.
It would be desirable to combine a prosthestic valve type
with a specific type of aortic root geometry in order to obtain
a disturbance-free velocity field with low pressure drop. This
means that the extent of flow separation with backflow,
vortices and stagnation could be minimized. The mixing
zones between main flow and separation zones cause shear
stresseswhich may lead IO blood cell damage or activation.
On the other hand, stagnation areas arc prone to platelet
aggregation and thrombus deposition.
Especially for the design of new valve types it is important
to know the geometric configuration of the aortic root in
order to take directed design measures for the fluid mechan-
ical and functional improvement of the valve. In this context.
fluid mechanical model studies or calculations with typical
model geometries play a major role.
This study is intended to classify the geometrical changes
of the aortic root for dillercnt types of aortic valve diseases
and to provide parametric data for the individual geometries.
2. MATERIAL
For the evaluation of parametric data of aortic root
geometries angiographic film material of the Medical Clinic I
ofthe RWTH Aachen was available. Out of IS.000 films. 604
were preclassified according to the NYHA guidelines and
evaluated for the present study. All angiograms were taken
from a Mdegree right anterior view, showing a clear aspect of
the aortic root. Among the IS.000 films. which were obtained
during the last 20 years, 21 films which show the status after
prosthetic valve replacement could also be evaluated.
Received inJinal/orm 22 June 1989.
The films were projected onto a film monitor and the
geometrical data were measured by means of scaled templa-
tes. All measurements were taken in the mid-systolic phase.
During this phase the angiographic films showed clear and
easily measurable frames. Figure I gives an example. The
parametric system for the description ofaortic root geometry
was chosen according to Naumann and Kramer (1970) and
Kramer et al. (1976). The parameters D,. D,. L, and L, are
uniformly normalrfed with the ostium diameter Do (see
Fig. 2).
3. I. Esrimate o/ the measuriny error
Since the orientation of the longitudinal axis of the aortic
root physiologically lies within a broad range, it had to be
proven that a rotation of the aorta around its longitudinal
axis had no decisive influence on the measurement results
taken from the two-dimensional screen projection. For the
following details please refer to Fig. 3.
The cross-section of the aortic sinus can be approximately
described by an epitrochoid. An epitrochoid is defined as a
curve, generated by a point(P) which lies inside a circle which
again rolls on the perimeter of a second circle. If the point (P)
lies on the perimeter of the rolling circle, as also depicted in
Fig. 3. the resulting curve is an epicycloid. The shape of the
epitrochoid is a function of the quotient of the respective
circle diameters. If. for instance, the diameter ratio of the
inner and outer circles is 3: I. the outer circle rotates three
times around its axis during a complete 360 path around the
fixed inner circle. Since, in the case of the epitrochoid. the
point (P) lies on the radius (b) of the smaller circle, the
relation 1= e/b determines the characteristic shape of the
epitrochoid. whereby @ is the distance between the center
(C) of the rolling circle and the point (P). The projected
parameter (D,) is equal to the distance of the vertical
tangentsat thecpitrochoid.Therefore. it has to beshown that
the projected vertical tangent spacing for arbitraty aspect
angles is within an acceptable range for data evaluation (i.e.
approximately constant).
In cartesian coordinates the cpitrochoid quation can be
written as (Bronstein-Semendjajew. 1981):
x=(a+b)cosz-Ibcos((a+b)/(bz)) (I)
y =(a+b)sinz-Lbsin((R+r)/(bz)). (2)

I81
 182 Technical Note
Fig. 2. Geometrical parameters for the characterization of
the aortic root: Do = orifice diameter. D, = aortic diameter
distal to the sinus. D, = maximum projected sinus diameter,
L,=length of the sinus. t,=distance between Do and D,.
Fig. 3. Illustration of the aortic root cross-section by an
epitrochoid and the corresponding dimensionsof projcxtion.
For aortic sinuses a value of I between 0.4 and 0.7 can be
assumed (verified by casts of human aortas, our unpublished
data). Because of the anatomical symmetry of 3 x 120 the
diameter ratio o:b=3:I.
A mathematical calculation for the special case of an
epilrochoid with I= I (epicycloid) results in a minimal
projection of D,, = 9.04 b and a maximal projec1ion of D,
=9.74b. The real maximum diameler of D, (from the top
view) is. of course, D, = IO b. The average projected diameter
is Dvm9.4 b. From this calculation, a possible measurement
error of 3.7% results. For real i values between 0.4 and 0.7
the maximum measurement error reduces to values between
1.5% and 2.6% and is. therefore, negligible since the physio-
logical bandwidlh has a scatter of i20%.
4. RESULT8
4.1, Group I : normal values for healrhy patients
To demonstrate the change of aortic geometry due 10
vascular diseases, 206 films of healthy patients (without
valve disease) were also evaluated by the same method. From
these values a normal geometry was derived, which corres-
ponds to the most common shape of the healthy patient. The
comparable data of Swanson and Clark (1974) obtained from
casts of human aortas are significanlly different: Dr./Do
= 1.38, DA/Do = 1.0, L,/Do=0.87.L.,/Do=0.17.Thestatis1-
ical distributions of the various parameters are given in
Fig. 4A-D. the resulting geometry in Fig 9. The valves show
a normal distribution (in the statistical sense), the variation
coefficients have values of 7% for D,/ Do, 8% for DA/ Do and
LA/Do and 14% for Lv./Do. This means that 68% of normal
aortic geometries have anatomical deviations from the depic-
ted shape that are less than 8% (or less than 14% for LB/Do).
4.2. Group 2: patients with oorric valve stenosis
This second group consists of I I I patients. The geomet-
rical change of the aortic root shows a high dependency on
the degree and the duration of the valve disease. Except for
LA/Do all other parameters show two maxima. whereby the
first maximum with slight deviation from the normal value
contains the mild cases. The measurement values are depic-
ted in Fig. SA-D.
The distribution of the parameters leads to two dilferent
geometries. one for a mild stenosis and one for a severe
stenosis (cf. Fig. 9).
4.3. Group 3: parirnts wifh aortic calve insujiciency
This group contains I22 patients. Here also. the respective
parameters show two maxima. correlated with the degree of
insufficiency (Fig. 6A-D). The generally smaller values
D,/D,. DA/D,, LA/Do. and L,/D, as compared to the
normal values can be attributed to the increase of Do and not
to a decrease of sinus size. The measurements indicate that
aortic valve insufficiency primarily causes a dilatation of the
ostium ring (Do). Here also. from the parameter distribution,
two geometries result which can be correlated to a mild and a
severe valve insufficiency (cf. Fig. 9).
4.4. Group 4: patients wirh combinrd valvular disease
The group of patients with combined valvular diseases
contains I44 patien1s. Within this group, an association with
specilic geometrical aortic root types was not possible. Since
the geometrical changes compensate each other. a dilatd
os1ium diameler (Do) at simultaneously increased values D,.
D,. L, and L, gives the impression of a normal geometry
(Fig. 7A-D). The other resulting geometries can tither be
attributed to 1hc geometrical type of stenosis or insulliciency.
4.5. Group 5: puricnrs u/rer vulve replacement
This smallest group con1ains 21 patients after aortic valve
replacement. Because of the low number a type-classification
cannot be made. The scatter of measurement values is high
since the investigated patients usually had a variety of
complications requiring a supplementary angiography. This
patien1 group also shows very often scarred alterations
within the aortic root, which additionally influence the
geometry.
It should be mentioned, though, that concerning the
parameters D,/ Do and DA/ Do more than 50% of all patients
can be attributed to healthy or severe insufficiency groups
(cf. Fig. 8A and B).
4.6. Krsulring characteristic oortic root gcomctrirs
The measured data arecompiled in Table I. Becauseof the
roentgenographic evaluation method, the parameters Do,
L,. L, and D, are projected in true scale (cf. Fig. 2). The
parameter D,, however, comprehends a plane projection of
the aortic sinus and does not describe the geometrical
configuration of the aortic wall between the three sinuses.
Therefore. for a complete geometrical description, an appro-
priate estimation seems to be necessary.
The measured value D, may vary between a minimum and
a maximum; the average is 0.94 times the epicycloid value.
Therefore. the following equation can be formulated:
Fig. I. Angioyrsphic film frame of an eorlic root with indicated measurement paranrclcrs.

183
 Techmcal Note

(A)

1.30 1.35 1.40 1.45 1.50 1.55 1.60 1.65 1.70 1.75 1.60

+ (Cl
3
a 70-
6 Max 1.0
L 6a-

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i 60.

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30-

0.75 0.6 0.65 0.9 0.95 1.0 1.05 1.10 1.15 1.2 1.25 1.3

LAlDo

0.15 0.20 0.25 0.30 0.36 0.40 0.45 0,Y) 0.55 0.60
woo

Fig. 4. Statisticai distribution of the normalized geometrical parameters for shape I: normal geometry.
186 Technical Note

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Technical Note
188 Technical Note

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 Technical Note

x=0,5 x=0&5 xaq70

SHAPE 1 SHAPE 2 SHAPE 3

lORNA1 UILD STElOSlS SEIEllE STEWOSIS

x*q4

SHAPE 4 SHAPE 5
NIL0 IlSUFFlClElCY SEVERE INSUFFICIENCY

Fig. Y. Compiled geometries of the characterislic shapes l-5 based on the complete parameter sets of
Tables I and 2.

Table 2. Normalized values for r,,,., and rmin

Shape WD, DliDa i. r,.,lD, r,,.lD0

I 1.55 1.25 0.5 0.82 0.64

2 1.61 1.18 0.65 0.86 0.62
3 1.72 1.15 0.7. 0.9 I 0.64
4 1.49 I .23 0.54 0.79 0.60
5 1.37 1.31 0.4 0.73 0.60

5. DISCUSSION
The results allow the conclusion that specific valvular
diseases are correlated with characteristic changes of aortic
root geometry. According to the present study, these changes
can be classified into five different characteristic groups. The
patients with combined aortic valve diseases and after valve
replacement cannot be attributed to these categories, since
no distinct parameter set exists. The results for valve stenoses
and insufftciencies indicate that first a compensatory geo-
metry exists (first maximum of the parameter curves), which
is then followed by a more distinct geometrical alteration in
the phase of decompensation (second maximum).
For model investigations at aortic heart valve prostheses
this study provides important basic geometrical data. By
appropriate modeling of the evaluated geometrical aortic
 Technical Note I9f

root types. the flow fields at different valve types and the geometrie auf die Durchstromung kiinstlicher Herzklar+
mutual interaction between valve geometry and surrounding pen. Z. Kardiol. 3. 57.
geometry can be investigated. This may eventually lead to the Muller, T. J.. Lloyd, J. R., Chetta, G. E. and Galanga, F. L.
selection of a specific valve type for a given aortic root (1975) Effect of test section geometry on the occluder
geometry or be useful for better valve designs. motion of caged-ball prosthetic heart valves. Biomrch.
Symp., A,VfD 10, 188.
Naumann, A. and Kramer, J. (1970) Flow investigations at
artificial heart valves. AGARD Proc. 65, 5.
Reul, H. and Talukder. N. (1979) Heart valve mechanics.
REFERENCES Quantirurice Cardiocascular Studies (Edited by Hwang, N.
H. C. et ~1.). pp. 527-564. University Park Press, Baltimore.
Bellhouse, B. J. and Talbot, C. (1969) The fluid mechanics of Swanson, W. M. (1975) Sinuses of valsalva: structural an,d
the aortic valve. .I. Ffuid Mech. 35, 721-735. flow evaluation. Proc. 28th Ann. Con& on Engng Med. Biol.,
Bronstein-Semendjajew. X. (1981) Taschenbuch der Marh- New Orleans. p. 259.
ematik. Veriag Harri Deutsch, Zurich. Swanson, W. M. and Clark, R. E. (1974) Dimensions and
Kramer, C., Gerhardt, H. J., Bleifeld. W. and Schwerin. H. geometric relationships of the human aortic valve as a
(1976) Modelluntersuchungen zum EinfluD der Aorten- function of pressure. Circulation Res. 3s. 871-882.