Advanced 3D Echocardiographic Assessment of the Aortic Valve and Aortic Root Complex: A Repair-Oriented Perspective

Abstract

The aortic valve (AV) and aortic root complex constitute a functional unit, and their integrated anatomical and dynamic assessment is essential for the management of AV disease. Owing to close collaboration with cardiac surgeons, three-dimensional echocardiography (3DE) has significantly expanded the diagnostic information provided by imaging cardiologists and has a key role in guiding therapeutic strategies. This is particularly relevant in patients with significant aortic regurgitation (AR) undergoing evaluation for valve repair or valve-sparing procedures. Detailed anatomical assessment of the cusps allows characterization of valve morphology and tissue quality, while multiplanar reconstruction enables accurate measurement of key structures, including the virtual basal ring and coronary ostial height. In addition, quantitative assessment of cusp geometry (effective, geometric, and coaptation height) permits precise identification of AR mechanisms, which is critical for guiding repair strategies and selecting appropriate surgical approach. In aortic stenosis (AS), 3DE contributes to the evaluation of discordant or borderline cases by improving left ventricular outflow tract assessment and allowing direct planimetric measurement of the AV area. Furthermore, 3DE provides complementary information in procedural planning for both transcatheter and surgical AV replacement, playing a particularly important role in patients with contraindications to computed tomography. Overall, 3DE, particularly in the transoesophageal setting, has become an essential imaging modality for integrating anatomical and functional information, thereby improving diagnostic accuracy and supporting a repair-oriented approach to tailored treatment in AR.