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In this next video, we're gonna talk about additional, uh,

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measurements that are important for assessing the aortic root.

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And these measurements really revolve around the idea of trying to assess risk,

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uh, for patients, uh, if, uh, of transcatheter valve is placed. Um,

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and so we're identifying various types of high risk anatomy, and those, uh,

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are in sort of broad strokes, low coronary arteries, nerve sinuses.

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And then, um, separately in a a separate video,

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we're gonna talk about heavily calcified, uh,

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left ventricular outflow tract and, uh, aorta mitral continuity.

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So first let's talk about the coronary osteo heights.

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So low coronary artery heights increase the risk for occlusion by displaced

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valve leaflets. So, uh, when you put the valve in,

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the leaflets are pushed out of the way, uh, into the sinuses.

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If the sinuses aren't, um, large enough and the coronaries are too low,

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then those disease leaflets may actually sit in front of the osteo for the

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coronary artery and obstruct blood flow. Um,

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and so this risk is minimized if the coronaries are tall and higher, uh,

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from the annular plane. And the key number here is 10 millimeters.

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We really want the coronary heights to be 10 millimeters.

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Now does that mean that a nine millimeter can't get a TAVR device? No. Um,

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it's just important to report these and have a discussion, uh,

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perhaps with your, uh, interventionalists.

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So they know that they need to take extra steps to be careful in these patients,

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or they may consider different types of devices, or in fact,

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they may consider doing a surgical valve replacement instead.

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So it's just all part of the overall assessment of the patient.

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The sinuses of salvo, as I mentioned,

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the disease leaflets are pushed into the sinuses after valve placement.

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So this is a patient with these diseased leaflets here. Um,

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you can see the level of this short axis image right in the middle of the, uh,

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sinuses, and you can see the chunks of calcification on these disease leaflets.

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Now, when the device goes in,

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it's the stent mounted valve and the leaflets actually are just pushed out of

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the way. And now they live inside of the sinuses here.

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And you can see this patient has quite a bit of space for these leaflets. Um,

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it's hard to see where there's a little bit of extra calcification that's

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related to these leaflets that's sitting in those sinuses. Um,

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and this is a good outcome. This is what you like.

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You would like to see nice wide sinuses that are gonna have enough space to

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accommodate these leaflets. Um, and so, uh, in order to, um,

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determine whether or not the patient has a big enough sinuses,

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we measure the sinus hits, widths and heights. Um, so how do we do that? Um,

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and we'll show you, um, with the case demonstration. Um,

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but these are just some images of the measurements that we make. Um,

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the sinus widths we take at the middle, uh,

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the biggest part of the sinuses and we take cusp to commissure measurements.

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So you can see it's the commissure between the two cusps to the opposite, um,

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cusp here. Uh, we do three of them, and then you take the average of the three.

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Um, the key number here is around 25 millimeters. Um,

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so narrow sinuses,

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less than 25 millimeters on average are gonna increase the risk for coronary

2:56

obstruction. And then sinus heights, we

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Measure from that basal plane.

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So you go to the basal most insertion of the coronary artery,

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and then you measure upward to the sin oft tubular junction. Um,

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you do that for all the different sinuses, and you take the average, uh,

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just like with the widths and less than 15 millimeters,

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that's considered short sinuses.

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And that would also increase the risk for coronary obstruction.

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So I just want to, in this slide,

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summarize the different measurements that we use for I roots.

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And they're all detailed in different videos in this course.

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So we just talked about sinus of el Salva heights, widths,

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and coronary artery heights. We talked about in a separate video,

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the measuring of the annulus video, how to measure the annulus itself.

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And then there are a couple different things that we also look at in the aortic

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root. Um, there's the, um, optimal fluoroscopic angles. So that's a separate,

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um, case video that we have as well as, um,

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videos on ancillary findings that we review, including anular, calcification,

3:52

and bicuspid valves.