Advanced 3D echocardiographic assessment of the aortic valve and aortic root complex: a repair-oriented perspective.

AIMS: 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. This review highlights the role of three-dimensional echocardiography (3DE) in the comprehensive evaluation of AV disease and its contribution to therapeutic decision-making. METHODS AND RESULTS: Owing to close collaboration with cardiac surgeons, 3DE has significantly expanded the diagnostic information provided by imaging cardiologists and has become a key tool for guiding therapeutic strategies. In patients with significant aortic regurgitation (AR), detailed anatomical assessment of the cusps enables characterization of valve morphology and tissue quality, while multiplanar reconstruction provides accurate measurements of the virtual basal ring, coronary ostial height, and other key anatomical structures. Quantitative assessment of cusp geometry, including effective, geometric, and coaptation heights, allows precise identification of AR mechanisms, thereby facilitating repair-oriented surgical planning. In aortic stenosis (AS), 3DE improves evaluation of discordant or borderline cases through enhanced assessment of the left ventricular outflow tract and direct planimetric measurement of AV area. In addition, 3DE provides complementary information for procedural planning of both transcatheter and surgical AV replacement, particularly in patients with contraindications to computed tomography. CONCLUSION: Three-dimensional echocardiography, particularly transoesophageal 3DE, has become an essential imaging modality for integrating anatomical and functional information. It improves diagnostic accuracy, supports individualized therapeutic planning, and plays a pivotal role in promoting a repair-oriented approach to the management of aortic valve disease.