Flow patterns in the aortic root and the aorta studied with time-resolved, 3-dimensional, phase-contrast magnetic resonance imaging: implications for aortic valve-sparing surgery

OBJECTIVE: Sparing the aortic valve has become a surgical option for patients who require repair of aortic root ectasia and have normal valve leaflets. Surgical approaches to valve sparing differ with regard to preservation of the native sinuses of Valsalva. The role of the sinuses and the importance of maintaining them remain controversial. METHODS: By using a time-resolved, 3-dimensional, phase-contrast magnetic resonance imaging technique, aortic root and aortic blood velocity data were acquired from 2 patients with Marfan syndrome 6 months after aortic valve-sparing surgery with straight Dacron grafts and contrasted with data from 6 normal volunteers. RESULTS: In normal aortas vortical blood flow became apparent in the individual sinuses after peak systole. The vortices filled the available space behind the valve leaflets and persisted until diastole, expanding and moving inward during aortic valve closure. In contrast, no vortices were observed in the postoperative patients with Marfan syndrome with negligible sinuses. CONCLUSIONS: Changes in supravalvular flow accompany loss of sinus architecture. Whether the presence, size, and velocity of supravalvular vortices affects the function or durability of the preserved aortic valve remains to be studied.     

Use of In Vivo Insert Molding to Form a Jellyfish Valve Leaflet

We developed an in vivo insert molding technique to form tissue‐derived biomaterials into the desired shape, and with sufficient strength and durability, for use in artificial organs. Molds of acrylic resin with inserted velour cloth were implanted under the skin of goats to form a circular leaflet for a jellyfish valve. The valve leaflets were successfully produced in the molds after 17–60 days. Dense connective tissue covered the velour cloth, and loose connective tissue was formed within it. Tissue was radially formed from the hole in the mold. The tissue was simultaneously formed and shrunk. It is necessary to increase the connected portion between the tissue inside and outside the mold so that the tissue can completely cover the inserted materials without shrinkage.     

Coronary flow characteristics after a Bentall procedure with or without sinuses of Valsalva.

OBJECTIVES: The sinuses of Valsalva are known to contribute to the normal function of the aortic valve. Little is known about their role in promoting coronary artery blood flow. The aim of this study was to compare coronary artery flow characteristics among patients undergoing a Bentall operation by means of a conventional cylindrical Dacron conduit or with a new conduit with pseudosinuses of Valsalva or in patients retaining their natural sinuses of Valsalva after aortic valve and supracoronary ascending aorta replacement. METHODS: One year after a Bentall procedure with a standard cylindrical Dacron conduit (7 patients, group A) or with the new conduit (7 patients, group B), or after aortic valve and ascending aortic replacement (control group, 7 patients, group C) coronary flow velocity reserve and diastolic to systolic time integral ratio at baseline and after maximal hyperemia (with 40 microg of adenosine) were assessed by using a 0.014-in. Doppler guidewire positioned in the middle portion of the left anterior descending coronary artery. All patients were in NYHA class I, sinus rhythm and free of coronary disease. RESULTS: Arterial blood pressures and heart rate were comparable among groups. Intracoronary Doppler measurements did not show any significant difference in coronary vascular reserve between the three groups (3.6+/-0.4 vs 3.1+/-0.7 vs 3.7+/-0.5, P = 0.2). A greater diastolic component at baseline was present in group B patients (5.5+/-1.9 vs 3.5+/-0.9 in group A and 3.7+/-0.9 in group C, P = 0.024). After maximal hyperemia the diastolic component increased slightly in group A patients (8%) while both in groups B and C significantly decreased (-15 and -20%, respectively) (P = 0.017). CONCLUSIONS: The presence of pseudosinuses of Valsalva does not influence coronary flow reserve. After maximal coronary vasodilation the increase in the systolic component of coronary flow is more evident in the presence of sinuses or pseudosinuses of Valsalva, thus suggesting that coronary flow pattern may be affected by the presence of sinuses.     

Hydrodynamic evaluation of three artificial aortic valve chambers

The effect of chamber geometry on the characteristics of turbulent steady flow through a newly designed artificial heart valve, "the jellyfish valve," has been investigated for flow rates matching those of peak systole. Laser Doppler Anemometry (LDA) was employed to determine the velocity and shear stress distributions at various locations downstream of the jellyfish valve. Three geometrically different aortic valve chambers have been investigated: namely, a chamber with sinuses of Valsalva, an ellipsoidal chamber, and a cylindrical chamber. The results of this investigation indicated that the aorta with sinuses of Valsalva model had the highest turbulent shear stresses whereas the ellipsoidal model gave the highest-pressure drops. However, for the various flow rates examined, including the systole peak value of 26 L/min, it appears that the ellipsoidal model displays better hydrodynamic characteristics in terms of shear stress and uniformity of axial velocity distributions downstream of the jellyfish valve.     

The ideal theoretical graft oversizing in valve-sparing aortic operations with a standard tubular or a Valsalva graft

Objective: We sought to determine, by a mathematical model, the ideal theoretical degree of ascending aortic graft oversizing needed to obtain normal sinuses dimension in the reimplantation type of valve-sparing aortic operations. Methods: To define a normal-range value, size of sinuses of Valsalva was conventionally expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area (BLA), and measured in 50 healthy subjects. A mathematical relationship between aortic annulus diameter, aortic sinuses diameter and resulting BLA was defined. By simulating intra-operative scenarios, the effect of different degrees of a standard or Valsalva graft oversizing on BLA extension was tested. Results: The same degree of graft oversizing resulted in a bigger beyond leaflets area for the Valsalva graft than for a standard graft. Oversizing degrees exceeding +7 mm for a standard graft and +3 mm for the Valsalva graft resulted in a beyond leaflets area over normal limits. Results were expressed in a visual form as two different normograms, one for the standard graft and one for the Valsalva graft. Conclusions: A less pronounced graft oversizing is needed to achieve normal-range sinuses size when using a Valsalva graft, the ideal theoretical graft oversizing was +7 mm for a standard graft and +3 mm for the Valsalva graft, our normograms can be helpful in selecting a proper graft size when performing a valve-sparing aortic procedure.     

An In Vitro Feasibility Study of the Influence of Configurations and Leaflet Thickness on the Hydrodynamics of Deformed Transcatheter Aortic Valve

Clinically, the percutaneous transcatheter aortic valve (TAV) has been reported to be deformed in a noncircular configuration after its implant. The deformation is universal and various, and it leads to serious leakage and durability problems. Even in the same deformation, the leaflets made in different tissue thicknesses may cause different hydrodynamic performances. Simulating the left heart cardiac conditions by a pulse duplicator system, the present study investigated the effects of the aortic annulus deformation and the leaflet tissue thickness on the hydrodynamics of the TAV. Three 22 mm self‐expanding TAV samples were fabricated with three different leaflet thicknesses (0.25, 0.4, 0.55 mm). Every sample was successively deformed to be elliptical, triangular, and undersized circular shapes. The hydrodynamics of the TAV were assessed through a quasi‐physiological artery pulsatile flow duplicator system. The transvalvular pressure difference, effective orifice area, and regurgitation flow were determined. High‐speed video recordings were taken to investigate the leaflet kinematics. The results showed that the triangular deformation produced the poorest valve function while the elliptical deformation led to the slightest difference from the nominal. With increasing leaflet thickness, the effect of configuration deformation on the regurgitation increased. The thinner leaflets were better than the thicker ones in adapting to the deformation but had a higher risk of deterioration.     

Clinical introduction of a novel prosthesis for valve-preserving aortic root reconstruction for annuloaortic ectasia

OBJECTIVE: Most patients with annuloaortic ectasia are young. They are at risk for complications related to a lifetime of anticoagulation when composite grafts containing mechanical valves are used for reconstruction. The majority of patients have near normal valve cusps. Valve-preserving techniques have been developed to maintain valve function and avoid anticoagulation. The eddy currents occurring within the sinuses of Valsalva in the natural aortic root have been shown to be important in the smooth, gradual, and gentle closure of the valve. Compliance of the sinuses is important in reducing stress in the leaflets. A novel ascending aortic prosthesis with "built in" compliant sinuses (Robicsek-Thubrikar graft) was developed for clinical aortic root replacement. METHODS: Woven Dacron tubes were used to make the prostheses. Three precisely measured square pieces were cut to make the expandable, individual sinuses. Sewing the individual neo-sinuses to a scalloped end of the Dacron tube graft created the neo-sinotubular junction and sinotubular ridge. Five patients with annuloaortic ectasia underwent valve-preserving aortic root reconstruction. RESULTS: All intraoperative transesophageal echocardiographic images after the valve-preserving procedure showed a normal appearing root with 10% radial expansion of each sinus in systole. The space between the cusps and neo-sinus wall in systole was normal. No patient has more than mild aortic regurgitation. CONCLUSIONS: Valve-preserving aortic root reconstruction with a novel Dacron prosthesis with compliant "built in" sinuses re-establishes normal aortic root geometry with near normal valve motion. This may enhance the durability of the valve-preserving operation.     

In vitro evaluation of a new aortic valved conduit

BackgroundThis study examined whether the presence of a sinus of Valsalva equivalent in the KONECT RESILIA aortic valved conduit (Edwards Lifesciences, Irvine, Calif) improves valve hemodynamics, kinematics, and performance.MethodsA 28-mm KONECT RESILIA aortic valved conduit was used to create an in vitro flow test model, and the same aortic valved conduit model without a sinus section was used as a control. Particle image velocimetry and hydrodynamic characterization experiments were conducted in the vicinity of the valves in a validated left-heart simulator at 3 cardiac output levels. In addition, leaflet kinematics of the valves were determined through en face high-speed imaging.ResultsThe KONECT RESILIA aortic valved conduit model exhibited lower mean and peak transvalvular pressure gradients than the control model at all 3 cardiac outputs. In addition, its leaflets opened more fully than did those of the valved conduit without the sinuses, yielding greater effective and geometric orifice areas. It was found that the presence of the sinuses not only facilitated the development of larger and more stable vortices at the initial stages of the cardiac cycle but also helped to maintain these vortices during the late stages of the cardiac cycle, leading to smoother valve closure.ConclusionsThe KONECT RESILIA aortic valved conduit reproduces the bulged section of the aortic root corresponding to the sinuses of Valsalva. With this Valsalva-type conduit, larger orifice areas were observed, improving valve hemodynamics that may enhance performance.     

Valsalva prosthesis in aortic valve-sparing operations

Aortic valve-sparing operations have provided very good clinical outcomes. However, the absence of the sinuses of Valsalva might limit valve durability. The Gelweave Valsalva prosthesis, which presents pre-fashioned neo-sinuses, has been designed in order to avoid early leaflets deterioration. We report our results in 63 patients who underwent valve-sparing operations (reimplantation technique) using the Gelweave Valsalva graft. The main indication was ascending aorta aneurysm or annuloaortic ectasia, with or without aortic insufficiency. The operation was performed also in cases of Marfan syndrome, Bicuspid Aortic Valve (BAV), and acute Type A dissection. In-hospital mortality was of 4.7%, and two thirds were acute Type A dissection patients (P=0.01). There were no late deaths. Three years freedom from grade 3-4 AI and freedom from late aortic valve replacement were 91.7+/-4.3% and 93.8+/-5.1%, respectively. Aortic valve-sparing operations show good results in patients electively operated for aortic root ectasia. Aortic cusps repair may lead to late failure. Even if the Gelweave Valsalva prosthesis is easy to implant and it also reproduces pseudosinuses, a long-term follow up is necessary to determine if this graft may reduce leaflets deterioration.     

Mechanical Stress as Cause of Aortic Valve Disease Presentation of a New Aortic Root Prosthesis

We present an overview of studies on the aortic valve and propose that mechanical stress is a main causative factor in the degenerative valvular disease. In the normal aortic valve, the leaflets have a smooth surface, free of wrinkles and creases, throughout the opening process. This smooth leaflet surface during motion is achieved by the “pull and release” movement of the commissures, which occurs because of the compliance of the aortic root. When the aortic root is stiffened, either by artificial means or by the loss of elasticity due to aging, the leaflet dynamics change significantly. The leaflets develop a significant number of creases and wrinkles during the opening process. In the bileaflet valve, the leaflets develop similar creasing and wrinkling during the opening process. This happens mainly due to the less-than-ideal design of the bileaflet valve and in spite of the compliant aortic root. When the aortic valve is spared using a noncompliant tube graft, a similar phenomenon of leaflet creasing occurs. Because the creasing produces high stresses from bending and buckling, it is damaging to the leaflet tissue and can lead to degenerative and calcific valvular disease. Based on these observations a new aortic root prosthesis with compliant sinuses has been designed for the valve sparing operation.     

Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit

BACKGROUND: The durability of aortic valve-sparing procedures is negatively affected by increased leaflet stress in the absence of normally shaped sinuses of Valsalva. We compared valve motion after remodeling procedures using a standard conduit and a specifically designed aortic root conduit. METHODS: Echocardiographic studies of the aortic valve dynamics were performed in 14 patients after remodeling of the aortic root (7 standard conduits, group A; 7 new conduits, group B) and in 7 controls (group C). Opening and closing leaflet velocities and percent of slow closing leaflet displacement were measured. Root distensibility and the pressure strain of the elastic modulus were measured at all root levels. RESULTS: Root distensibility and the pressure strain of the elastic modulus were different in group A and B only at the sinuses (p < 0.001). Opening and closing leaflet velocities were not different among groups. Slow closing leaflet displacement was markedly more evident in group B patients (24.2%+/-1.9% versus 2.5%+/-1.9% in group A, p < 0.001) and similar to controls (22.1%+/-7.9%). CONCLUSIONS: The new conduit guarantees dynamic features of the aortic valve leaflets superior to those obtained with standard conduits and more similar to normal subjects.     

Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation.

BACKGROUND: We assessed the results of a modified technique for aortic root reconstruction including preservation of the native aortic valve and sinuses. METHODS: A modified technique for reconstruction of the aortic root was devised in which the native aortic sinuses are preserved and remodeled, the diameter of the sinotubular junction is reduced, the ventriculoaortic junction is reinforced with a Dacron prosthesis, and the coronary ostia are reimplanted. Since January 1995, this modified operative technique was performed in 13 patients with a mean age of 54 +/- 21 years. The median grade of aortic regurgitation was 3; in 10 patients it was caused by dilatation of the sinotubular junction, and 3 had additional annuloaortic ectasia. RESULTS: The aortic crossclamping time was 61 +/- 18 minutes. In-hospital mortality was 2 of 13 (15. 3%) patients, both deaths being related to complications of aortic dissection. In 1 patient aortic regurgitation increased to grade 3, necessitating aortic valve replacement. At a mean follow-up of 2.1 years, the remaining 10 patients had stable aortic valve function with a median grade of regurgitation of 1. The mean New York Heart Association functional class was 1.2. CONCLUSIONS: Aortic root reconstruction with preservation of the native aortic valve and sinuses allows symmetric reconstruction of the aortic sinuses and adaptation of the diameters of the sinotubular and ventriculoaortic junctions, thus optimizing aortic valve function. Moreover, it prevents contact of the aortic valve leaflets with the Dacron graft, which may enhance the durability of the repair.     

Extensive aneurysms of sinuses of Valsalva precluding valve sparing aortic root reimplantation (David procedure)

A 55-year-old female noticed worsening exertional dyspnoea for two years. She was born with cleft palate and profound deafness. Significant physical findings included dysmorphism with micrognathia and acrocephaly and congenital deafness. Transthoracic echocardiogram revealed aneurysms involving the right and the non-coronary sinuses of Valsalva. Despite that, the native aortic valve retained preserved geometry. Computed tomography (CT)-scan demonstrated multiple aneurysms arising from all three sinuses of Valsalva. This displaced the right ventricle (RV) caudally and indented the RV outflow tract. A valve-sparing root reimplantation was planned. However, intraoperatively the root aneurysms were found to be very extensive such that no healthy tissue remained along the insertion lines of the aortic valve leaflets. The aortic annulus was not dilated (2 cm) and the left ventricular outlow tract was not involved in the disease process. Consequently, despite the presence of macroscopically normal leaflets and relatively undisturbed annular geometry, we were unable to reimplant the native aortic valve and proceeded to a modified Bentall procedure. Histologically, significant medial degeneration with loss of elastin and muscle was identified in the aortic sinus wall. Similar changes were also found affecting the native leaflets coupled with increased fibrous thickening.     

Development of a polymer bileaflet valve to realize a low-cost pulsatile blood pump

The final goal of this study is to realize a low-cost pulsatile blood pump especially for patients with acute heart failure or postoperative low cardiac output syndrome. In support of the pump, two types of polymer bileaflet valves with different configuration of the valve seats were developed. Influence of the leaflet thickness on the hydrodynamics of the prototype was preliminarily investigated among 70 microm, 100 microm, and 150 microm. As to the valves with the thinner leaflets, buckling of the leaflets was observed, which induced a large amount of regurgitation at valve closure. However, by thickening the leaflet to 150 microm, the mean flow of the prototype and the second model could be successfully comparable to the Medtronic-Hall valve. Moreover, accelerated fatigue tests showed that reinforcement of the valve seat with the additional spokes in the second model extended the durability by four times as compared with the prototype, equivalent to an in vivo duration of over one month.     

Simple modification of "T. David-V" valve-sparing aortic root replacement to create graft pseudosinuses

The absence of sinuses of Valsalva is postulated to perturb coronary flow patterns and to create abnormal leaflet stresses, which theoretically may limit the long-term durability of valve-sparing aortic root replacement with the original Tirone David-I reimplantation technique with a cylindrical tube graft. David developed the “T. David-V” procedure in 2001; it creates large billowing Dacron pseudosinuses while retaining the reimplantation concept. To illustrate a simple modification of the T. David-V technique, we describe a patient with Marfan's syndrome who underwent valve-sparing aortic root replacement with 1 large and 1 small graft to create pseudosinuses in the Dacron graft, to facilitate suturing the valve inside the graft, and to make the distal graft-to-aorta anastomosis a better size match.     

In vitro performance of trans-valve left ventricular assist device installed at aortic valve position

In this study, we developed a trans-valve left ventricular assist device (LVAD) that unites a rear-impeller axial-flow blood pump (AFBP) and a polymer membrane valve placed at the aortic valve position. The diameter and length of the rear impeller AFBP was 12 and 63 mm, respectively. The polymer membrane valve was similar to the jelly-fish valve consisting of a valve leaflet made of silicone rubber (thickness 0.5 mm), valve ring (diameter: 25 mm), and valve spokes. The trans-valve LVAD was examined in a mock circulation. An implantable pulsatile flow (PF) VAD was connected to an atrial reservoir to simulate the left ventricle (LV), and the Hall valve was worn in the inflow port, and the trans-valve LVAD was placed in the outflow port as an outflow valve. When the motor rotational speed increased to 26 400 rpm, the mean aortic flow increased from 4.2 to 5.3 L/min, mean aortic pressure increased from 83.4 to 100 mm Hg, and mean motor current of the implantable PF VAD decreased from 1.18 to 0.94 A (unloading effect on LV −21%). The energy equivalent pressure increased from 85.2 to 102 mm Hg, and surplus hemodynamic energy (SHE) decreased by −15.4% from the baseline. In conclusion, the trans-valve LVAD has an advantage of preserving pulsatility without any complicated mechanism and is a novel and promising LV support device.     

Experimental Setup to Evaluate the Performance of Percutaneous Pulmonary Valved Stent in Different Outflow Tract Morphologies

Percutaneous pulmonary valve implantation is a potential treatment for right ventricular outflow tract (RVOT) dysfunction. However, RVOT implantation site varies among subjects and the success of the procedure depends on RVOT morphology selection. The aim of this study was to use in vitro testing to establish percutaneous valve competency in different previously defined RVOT morphologies. Five simplified RVOT geometries (stenotic, enlarged, straight, convergent, and divergent) were manufactured by silicone dipping. A mock bench was developed to test the percutaneous valve in the five different RVOTs. The bench consists of a volumetric pulsatile pump and of a hydraulic afterload. The pump is made of a piston driven by a low inertia programmable motor. The hydraulic afterload mimics the pulmonary input impedance and its design is based on a three element model of the pulmonary circulation. The mock bench can replicate different physiological and pathological hemodynamic conditions of the pulmonary circulation. The mock bench is here used to test the five RVOTs under physiological‐like conditions: stroke volume range 40–70 mL, frequency range 60–80 bpm. The valved stent was implanted into the five different RVOT geometries. Pressures upstream and downstream of the valved stent were monitored. Flow rates were measured with and without the valved stent in the five mock RVOTs, and regurgitant fraction compared between the different valved stent RVOTs. The percutaneous valved stent drastically reduced regurgitant flow if compared with the RVOT without the valve. RVOT geometry did not significantly influence the flow rate curves. Mean regurgitant fractions varied from 5% in the stenotic RVOT to 7.3% in the straight RVOT, highlighting the influence of the RVOT geometry on valve competency. The mock bench presented in this study showed the ability to investigate the influence of RVOT geometry on the competence of valved stent used for percutaneous pulmonary valve treatment.     

Pulsatile flow past St. Jude Medical bileaflet valve. An in vitro study

An in vitro hemodynamic study of the St. Jude Medical bileaflet aortic prosthesis was performed in a mock circulatory system simulating physiological pulsatile flow. The study included measurements of pressure drop across the valves, percent regurgitation, velocity, and turbulence in a model human aorta. The measurements indicated that pressure drop (mean systolic pressure drop of 6.2 mm Hg), percent regurgitation (10.15%), and turbulent normal stresses immediately downstream from the valve (825 dynes/cm2) were better than those with other prosthetic valves and bioprostheses. The flow development in the aorta was not significantly affected by the orientation of the bileaflet valve in the root of the aorta. However, velocity measurements immediately downstream from the valves showed flow reversal and separation in the vicinity of the hinge points of the leaflets where thrombus formation has been previously reported.     

Tissue engineering of heart valves: in vitro experiences

BACKGROUND: Tissue engineering is a new approach, whereby techniques are being developed to transplant autologous cells onto biodegradable scaffolds to ultimately form new functional tissue in vitro and in vivo. Our laboratory has focused on the tissue engineering of heart valves, and we have fabricated a trileaflet heart valve scaffold from a biodegradable polymer, a polyhydroxyalkanoate. In this experiment we evaluated the suitability of this scaffold material as well as in vitro conditioning to create viable tissue for tissue engineering of a trileaflet heart valve. METHODS: We constructed a biodegradable and biocompatible trileaflet heart valve scaffold from a porous polyhydroxyalkanoate (Meatabolix Inc, Cambridge, MA). The scaffold consisted of a cylindrical stent (1 x 15 x 20 mm inner diameter) and leaflets (0.3 mm thick), which were attached to the stent by thermal processing techniques. The porous heart valve scaffold (pore size 100 to 240 microm) was seeded with vascular cells grown and expanded from an ovine carotid artery and placed into a pulsatile flow bioreactor for 1, 4, and 8 days. Analysis of the engineered tissue included biochemical examination, enviromental scanning electron microscopy, and histology. RESULTS: It was possible to create a trileaflet heart valve scaffold from polyhydroxyalkanoate, which opened and closed synchronously in a pulsatile flow bioreactor. The cells grew into the pores and formed a confluent layer after incubation and pulsatile flow exposure. The cells were mostly viable and formed connective tissue between the inside and the outside of the porous heart valve scaffold. Additionally, we demonstrated cell proliferation (DNA assay) and the capacity to generate collagen as measured by hydroxyproline assay and movat-stained glycosaminoglycans under in vitro pulsatile flow conditions. CONCLUSIONS: Polyhydroxyalkanoates can be used to fabricate a porous, biodegradable heart valve scaffold. The cells appear to be viable and extracellular matrix formation was induced after pulsatile flow exposure.     

A normogram to anticipate dimension of neo-sinuses of valsalva in valve-sparing aortic operations.

OBJECTIVE: The aim of the present study was to define a method to pre-determine the correct size of neo-sinuses of Valsalva in the reimplantation type of valve-sparing aortic operation. METHODS: The objective was achieved in three steps: (1) evaluation in the healthy population, of the normal size of sinuses of Valsalva expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area; (2) elaboration of a normogram by which, given a known annular diameter, it is possible to select the appropriate graft size to obtain a normal beyond leaflets area; (3) validation of the normogram by comparing, in a population of 20 patients undergoing a valve-sparing procedure, the predicted and observed beyond leaflets area. RESULTS: The following values for beyond leaflets area were observed: mean normal 320.6+/-120.6mm(2), mean predicted 355+/-63.2mm(2), mean observed 364.7+/-72.8mm(2).No significant differences were obtained for predicted versus observed values. Regression analysis showed a linear distribution with an r value of 0.95. CONCLUSIONS: We proposed a simplified approach for sizing of the neo-aortic root in the reimplantation type of valve-sparing aortic operation focussed on the size of sinuses of Valsalva. Our normogram showed to be reliable in anticipating beyond leaflets area. It can be helpful in avoiding the selection of an undersized or excessively oversized graft.