Received: 21 June 2022 Revised: 23 December 2022 Accepted: 23 December 2022

DOI: 10.1002/ca.24002

COMMUNICATION

Aortic valve fenestrations: Macroscopic assessment and

functional anatomy study

Damian Dudkiewicz 1 | Jorge D. Zhingre Sanchez 2 | Jakub Hołda 1 |

3 3 3
Filip Bolechała | Marcin Strona | Paweł Kopacz | Paul A. Iaizzo 2 |
Mateusz Koziej 1
| Mateusz K. Hołda 1,4,5
| Małgorzata Konieczyn
ska 4,6

1
HEART - Heart Embryology and Anatomy
Research Team, Department of Anatomy, Abstract
Jagiellonian University Medical College,
Aortic valve fenestrations are defined as a loss of aortic valve leaflet tissue. They are a
Cracow, Poland
2
Visible Heart® Laboratories, Departments of common but overlooked finding with unclear significance. The aim of this study was to
Biomedical Engineering and Surgery, Institute investigate the varied functional anatomies of aortic valve fenestrations. A total of
for Engineering in Medicine, University of
Minnesota, Minneapolis, Minnesota, USA
400 formalin-fixed autopsied human hearts were macroscopically assessed and the
3
Department of Forensic Medicine, function of the aortic valve of 16 reanimated human hearts were imaged using Visible
Jagiellonian University Medical College,
Heart® methodologies. Aortic valve leaflet fenestrations were present in 43.0% of
Cracow, Poland
4
Department of Diagnostic Medicine, John
autopsied hearts (in one leaflet in 24.0%, in two leaflets 16.0%, in all leaflets 3.0%). Fen-

w, Poland
Paul II Hospital, Krako estrations were mostly present in left (25.5%) followed by right (23.3%) and noncoron-
5
Division of Cardiovascular Sciences, The ary leaflet (16.3%). In 93.8% of cases, the fenestrations form clusters and were mainly
University of Manchester, Manchester, UK
6
located at the free edge of the leaflet in the commissural area (95.4%). Hearts with aor-
Department of Thromboembolic Diseases,
Jagiellonian University Medical College, tic valve fenestrations had significantly larger aortic valve diameters and aortic valve
Cracow, Poland
areas (p < 0.001). The average surface area sizes of fenestrations were 23.8
Correspondence ± 16.6 mm2, and the areas were largest for left followed by right and noncoronary leaf-
Mateusz K. Hołda, HEART - Heart Embryology
let fenestrations (p < 0.001). The fenestration areas positively correlated with donor age
and Anatomy Research Team, Department of
Anatomy Jagiellonian University Medical (r = 0.31; p = 0.02). Significant hypermobility and subjective weakening of the leaflet

w,
College, Kopernika 12, 31-034 Krako
adhesion levels of the fenestrated regions were observed. In conclusion, fenestrations
Poland.
Email: mkh@onet.eu of the aortic leaflets are frequent, and their sizes may be significant. They occur in all
age groups, yet their size increase with aging. Fragments of leaflets with fenestrations
Funding information
Narodowe Centrum Bada
n i Rozwoju, show different behaviors during the cardiac cycle versus unchanged areas.
Grant/Award Number: LIDER/7/0027/L-
10/18/NCBR/2019
KEYWORDS
aorta, aortic cusp, aortic fenestration, aortic leaflet, aortic root, aortic valve, fenestrated cusp,
fenestrated leaflet, sinus of Valsalva

1 | I N T RO DU CT I O N
Aortic valve fenestrations, defined as an aperture/loss of tissue in the
human aortic valve leaflets are common, but often overlooked enti-
ties, with unclear significances (Ashalatha & Hannah Noone, 2017;
Friedman & Hathaway, 1958; Roberts et al., 2019; Whiteman
et al., 2020; Zhu et al., 2020). It is estimated that they may be present
in every second human, and in all age groups (Zhu et al., 2020). As the
fenestrations may be observed already in fetal life, they perhaps
should be considered as a congenital form of tissue atrophy
(Foxe, 1929). Fenestrations may be found in all of the three leaflets of
the aortic valves, as well as presenting in bicuspid or quadricuspid
valves (Mizoguchi et al., 2014; Yang et al., 2019). Although the fenes-
trations tends to be located preferably in the commissural valve

© 2023 American Association of Clinical Anatomists and British Association of Clinical Anatomists.

612 wileyonlinelibrary.com/journal/ca Clinical Anatomy. 2023;36:612–617.


DUDKIEWICZ ET AL.
regions, they can occur in any place of any valve leaflet (Zhu
et al., 2020).
It is still not entirely clear, whether fenestrations in aortic valve
leaflets may play significant role in the pathophysiologies of various
aortic valve diseases (Zhu et al., 2020). Nevertheless, the presence of
the aortic leaflet fenestrations has been linked to hemodynamically
significant aortic valve regurgitations (Yang et al., 2013; Zhu
et al., 2020); especially, if large and centrally located apertures in the
leaflet structure are present which may be responsible for a leaky
valve (Jodati et al., 2014). The presence of the fenestrated regions
within the valvular tissues may lead to the significant losses of leaflet
stiffnesses and therefore be associated with prolapses (Yang
et al., 2019). Moreover, a fenestrated leaflet may be more prone to
rupture, which can lead to massive regurgitation and/or acute aortic
valve insufficiency (Moran et al., 1977; Zhu et al., 2020). Finally, the
course of the invasive procedures targeted to the aortic valve could
be negatively influenced by presence of fenestrations (Algarni
et al., 2015).
Despite several autopsy and intra-operative studies in addition to
many case reports describing the fenestrated aortic leaflets, still
today, relatively limited knowledge on this subject has been reported.
Therefore, the current study aimed to investigate aortic valve fenes-
trations based on macroscopic analyses of the largest to date samples
of human autopsied material and for the first time, evaluation of func-
tional visualizations of reanimated human hearts. Supplying such
information should increase our knowledge of the natures of aortic
valve fenestrations, therefore providing new insights into aortic valve
diseases and/or therapeutic interventions.
2 | MATERIAL AND METHODS
The study was conducted according to the principles expressed in the
1975 Declaration of Helsinki. The study protocol was approved by
the Bioethical Committee of the Jagiellonian University in Cracow,
Poland (Nos. 1072.6120.216.2019 and 1072.6120.275.2020) and by
the Institution Review Board at the University of Minnesota, MN,
USA. The authors state that every effort was made to follow all local
and international ethical guidelines and laws that pertain to the use of
human cadaveric donors in anatomical research (Iwanaga et al., 2022).
2.1 | Macroscopic assessment
Four hundred randomly selected autopsied human hearts (Caucasian)
of both genders (38.5% females) were examined macroscopically to
investigate the prevalences and distributions of the aortic valve leaflet
fenestrations. The mean age of donor organs was 46.3 ± 18.1 years,
and their mean body mass index (BMI) was 26.5 ± 4.2 kg/m2. Hearts
were collected at the Department of Forensic Medicine, Jagiellonian
University Medical College in Cracow, Poland during routine forensic
medical autopsies; those from the individuals who died as a result of
external causes (suicide, criminal acts, or accidents). Only hearts with
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613
no evident macroscopic cardiac pathologies, revealed during autopsy,
with no past cardiac surgery, no heart grafts, no heart trauma and no
macroscopic signs of cadaver decomposition were included in this
study. During these autopsies, hearts were dissected from the chest
cavity in a routine manner. Subsequently, hearts were washed and
fixed by passive immersion in 4% formaldehyde solution for at least
1 month prior to study.
After fixation, the aortic valve from each specimen was inspected
and measured. First, the ascending aorta was cut off from the aortic
root to expose the valve. Then, the aortic valve maximal diameters
and aortic valve area were measured from the aortic aspect at the
level of commissures. The given aortic valve was then cut at the level
of one of commissure (incision was made perpendicular to the aortic
root) to open the root to better expose all valvular elements. Aortic
valve fenestrations were defined as any gap or hole (space limited by
a fibrous strand) of at least 1 mm in diameter, that occurs in any part
of the aortic leaflet (Figure 1). The locations of the identified fenestra-
tions were noted, and the sizes (diameters) and the surface areas of
the fenestrations were measured. For the single fenestration, the sur-
face area was calculated using the mathematical formula for an oval
figure. To measure the surface area of the fenestration clusters the
shape of the cluster was first compared to a geometric figure (rectan-
gle, oval or trapezoid) and then the area was calculated using the
appropriate mathematical formula. To explore potential correlations
between the presence and sizes of aortic valve fenestrations and the
relative sizes of the given valve components, the lengths and heights
of all individual leaflets were measured.
All measurements were conducted using 0.03-mm precision elec-
tronic calipers (YATO, YT–7201, Poland). To reduce human bias, all
measurements were recorded by two independent investigators. If
results between the two researchers varied by more than 10%, both
measurements were repeated. The mean of the two new values was
calculated and reported as the final value.
2.2 | Functional anatomy investigation
Additionally, 16 fresh human heart specimens (75.0% females),
deemed nonviable for transplantation, were procured from organ
F I G U R E 1 Photograph of cadaveric heart specimen showing
aortic valve with large multiple fenestrations in the right leaflet in the
right/non coronary commissure area. F, fenestrations; N, noncoronary
leaflet; R, right coronary leaflet
 10982353, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ca.24002 by CochraneArgentina, Wiley Online Library on [14/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
614 DUDKIEWICZ ET AL.

donors as gifts for research by LifeSource (MN, USA) with informed
consent from the donor's closest relatives for the use of the hearts for
research purposes. The mean donor age was 61.0 ± 11.6 years at
death and the average BMI was 29.4 ± 4.8 kg/m2. Donated hearts
were arrested using a high potassium cardioplegic solution and
explanted using standard cardiac transplant procedures. The great
®
vessels were cannulated to allow for attachment to the Visible Heart
apparatus (Hill et al., 2005; Iaizzo, 2016). Then, each heart specimen
was re-perfused with a warm Krebs–Henseleit buffer to return the
specimen to a 37 C temperature. Hearts were then defibrillated to
achieve noninnervated sinus rhythms. Next, both 6 and 4 mm endo-
scopic cameras (Olympus Optical, Tokyo, Japan) were introduced to
aorta and used for real-time imaging of the functioning aortic valve
anatomy from the aorta-facing aspect of the valve (Hill et al., 2005).
Recorded videos were then analyzed for observations of the aortic
valve fenestrations and their relative behaviors throughout the cardiac
cycle.
2.3 | Statistical analyses
Data were provided as determining percentages or mean values with
corresponding standard deviations (±SD) with the minimum and maxi-
mum range. Shapiro–Wilk tests were used to determine normal distri-
butions, and Levene's tests were performed to verify relative
homogeneity of variances. Student's t- and the Mann–Whitney
U tests were used for statistical comparisons. Qualitative variables
were compared using chi squared tests of proportions with Bonferroni
corrections to account for the multiple comparisons. Correlation coef-
ficients were calculated to assess whether there was a statistical
dependence between the measured parameters. A p-value <0.05 was
considered statistically significant. Statistical analyses were performed
using StatSoft STATISTICA 13.3 software for Windows (StatSoft Inc.,
Tulsa, OK, USA).
3 | RESULTS
In 43.0% of all analyzed autopsied hearts at least one valvular fen-
estration was observed in any type of leaflet of the aortic valve
(Table 1). The youngest donor eliciting fenestrations was 18 years
old and the oldest 87 years old. Fenestrations were seen in only
one leaflet in 24.0% of specimens, in two leaflets in 16.0%, and in
all leaflets in 3.0% of all studied hearts. The fenestrations were
mostly present in left coronary leaflet (25.5%) followed by right cor-
onary leaflet (23.3%) and noncoronary leaflet (16.3%); the latter
being significantly less affected by fenestrations than other two
leaflets (p < 0.01). Single fenestrations (one single hole in the tissue)
were rarely observed (6.2% of all fenestrations), and most fenestra-
tions were made of multiple adjacent tissue defects (clusters)
(93.8%); as shown in Figure 1. According to the locations of the
fenestrations within the leaflet, they were mainly located at the free
edges of the leaflets in the commissural areas (95.4% of all fenestra-
tions); as shown in Figures 1 and 2. The right/left commissure
regions were the anatomic locations in which most fenestrations
were present (51.5% of all fenestrations) followed by right/
noncoronary commissure regions (29.2%) and left/noncoronary com-
missure regions (14.6%). Fenestrations located in the center of the
leaflet were rare (4.6%), and no fenestrations were noted being pre-
sent in the hinge-line regions. No gender differences were found in
the terms of fenestrations presences and/or distribution (all
p > 0.05). Moreover, no other anthropometric parameters (age, BMI)
had any influence on the presentations of valvular fenestrations.
Also, lengths and heights of all individual leaflets did not differ sig-
nificantly between valves with and without fenestrations (all
p > 0.05). On the other hand, hearts presenting with aortic valve
fenestrations elicited significantly larger aortic valve diameters (25.8
± 9.5 vs. 20.7 ± 4.5 mm; p < 0.001) and aortic valve areas (4.0 ± 1.5
vs. 3.2 ± 1.4 cm2; p < 0.001).
Table 1 shows dimensions of the leaflet fenestrations in the given
individual leaflets. In general, fenestration clusters were oriented
along the free edges of the leaflets (the supero-inferior diameter of
the fenestrations are significantly smaller than the transverse diame-
ters). While the supero-inferior diameters of fenestrations did not sig-
nificantly differ between leaflets; the transverse diameters were
found to be the largest for left leaflet fenestrations followed by right
and noncoronary leaflets (see Table 1, p < 0.001). The same trend was
observed for the areas of the fenestrations (left > right > noncoron-
ary, see Table 1; p < 0.001). No gender differences were observed rel-
ative to fenestration sizes. The fenestration areas were positively
correlated with donors age (r = 0.31; p = 0.02), but no significant cor-
relation was found relative to varied BMIs. Finally, the sizes of the

TABLE 1 Dimensions of the aortic valve fenestrations (mean ± SD with minimum-maximum range)

All Left coronary Right coronary Noncoronary p-Value,

Variable (n = 260) leaflet (n = 102) leaflet (n = 93) leaflet (n = 65) ANOVA
Fenestration supero-inferior 3.2 ± 1.9 3.3 ± 2.2 3.2 ± 1.8 3.0 ± 1.9 0.228
diameter (mm2) (0.5–11.4) (0.5–11.4) (0.6–7.4) (0.9–6.8)
Fenestration transverse diameter 7.6 ± 3.9 8.5 ± 3.7 7.4 ± 4.0 6.3 ± 3.8 <0.001
(mm2) (1.1–14.8) (1.5–14.8) (1.2–13.8) (1.1–10.1)
Fenestration surface area size 23.8 29.6 ± 22.7 23.7 ± 15.8 18.6 ± 12.9 <0.001
(mm2) ± 16.6 (1.8–80.4) (1.5–81.2) (1.5–62.1)
(1.5–81.2)

DUDKIEWICZ ET AL.
F I G U R E 2 Functional endoscopic
view of the aortic valve with multiple
fenestrations in leaflets. For more
functional images, see Videos S1 and S2
leaflets or the dimensions of the valves did significantly correlate with
the fenestration sizes (all p > 0.05).
In functional part of the study, behaviors of fenestrations during
the heart cycle in all studied hearts (see Videos S1 and S2) were visu-
alized. For these specimens, none of the aortic valves presented mac-
roscopically noticeable valvular disease. Fenestrations were present in
each investigated specimen and commonly located at the free edges
of the leaflets in the commissural areas and were mainly composed of
multiple tissue defects gathered in clusters. The qualitative analyses
of the recorded videos showed significant hypermobilities of the fen-
estrated regions throughout the cardiac cycles, when compared with
nonfenestrated fragments of leaflet tissues (tissue deflection, increase
in tissue strain during valve opening, see Videos S1 and S2). The fen-
estrated parts of the leaflets often disturbed the even aorta-facing
surfaces of the leaflets (protrusion of the fenestrations and fibrous
strands toward the Valsalva sinuses, see Video S2).
4 | DISCUSSION
Our present report is a unique combination of morphometrical assess-
ments of the large population of autopsied human hearts as well as
functional in vitro analyses of reanimated human hearts both studied
to investigate aortic valve leaflets fenestrations. To date, during the
last century, only four significant anatomical studies have investigated
and reported on aortic valve fenestrations (Ashalatha & Hannah
Noone, 2017; Foxe, 1929; Friedman & Hathaway, 1958; Losenno
et al., 2012). A recent meta-analysis of these studies showed the esti-
mated prevalence of aortic valve fenestrations to be a high 55.9% in
the general population (Zhu et al., 2020). Although the presence and
distributions of the fenestrations within the aortic valve have previ-
ously been studied, our study is the first to investigate complex ana-
tomic data in terms of fenestration dimensions. Significant
heterogeneities of the fenestration distributions can be observed
between leaflets (more in the left followed by right and noncoronary
leaflets). The average size of the fenestrations was significant and
measured at 23.8 mm2. Yet, very large fenestrations above 80 mm2,
in certain areas were present; these fenestrations occupy over one-
quarter of the surface of the given leaflet (Table 1). In addition, it was
observed that the largest fenestrations were commonly observed for
the left coronary leaflets (Table 1).
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615
Combining data from our current study with previous morpho-
logical reports, a clear image of the human aortic fenestrations' mor-
phological natures can be defined. Because of its high prevalence,
the vast majority of aortic valve fenestrations should be recognized
as subclinical variant of the aortic valve anatomy. Aortic valve fen-
estrations of different sizes and locations are present in almost
every healthy human being in all age groups (even fetuses) and in
all leaflets (Foxe, 1929). Therefore, it is safe to state that fenestra-
tions in the aortic valve leaflets are most likely of embryonic origin
and may be viewed as a well-advanced form of congenital tissue
anomaly (weakening and atrophy). Moreover, our finding suggest
that fenestrations are mainly located at the free edge of the leaflet
in the commissural area; in which the valve is subject to the great-
est hemodynamical and mechanical forces (turbulent blood flow)
leading to significant tissue tensile stress and distortion (Friedman &
Hathaway, 1958; Losenno et al., 2012). It may be hypothesized, that
continuous injury of the embryologically weakest points of the leaf-
let tissue may lead to formation or further propagation of the fenes-
trations. This hypothesis of lifelong fenestration evolutions may be
additionally supported by the observations from our study that the
identified fenestration sizes increased with aging. On the other
hand, aortic valve fenestrations that are subclinical, normal variant
of aortic valve anatomy should be differentiated from the clinically
relevant pathological fenestrations that may occur in the solid valve
leaflet during ulcerative endocarditis or as a result of sudden trauma
or iatrogenic injury.
Our uniquely employed methodologies allowed us to observe the
functional behaviors of the fenestrated aortic valves throughout the
cardiac cycle (Videos S1 and S2). Clearly, the presence of fenestrated
areas changes valve tissue behaviors in comparison to the solid por-
tions of the leaflets. Hypermobility of the fenestrated regions and
subjective weakening of leaflet adhesions in the coaptation zones
associated with fenestrations, were observed. Nevertheless, the
underlying questions relative to the clinical significance of these aortic
valve fenestrations remains unanswered. Yet, a recent report by Yang
et al. suggested that aortic valve fenestrations may account for 3.1%
of moderately severe and severe aortic valve insufficiencies (Yang
et al., 2019). Moreover, many case reports have described
fenestration-associated aortic valve regurgitations (Jodati et al., 2014;
Symbas et al., 1969; Zhu et al., 2020). Especially, the in the patient in
which the presence of multiple and large fenestrations exist, these

616
may have a significant impacts on the valve properties causing the
valve regurgitation. Because of their typical locations, fenestrations
should be particularly suspect when an eccentric regurgitant jet is pre-
sent (Akasaka et al., 2012). Furthermore, sudden and spontaneous
ruptures of fibrous strands within the fenestration may lead to acute
severe aortic valve insufficiencies or worsenings of chronic aortic
valve regurgitations (Irisawa et al., 2014; Akasaka et al., 2012; Mahara
et al., 2017). In summary, clinical observations confirm that the contri-
butions of aortic valve fenestrations are associated factors for the
development and/or deterioration of aortic valve insufficiency and
should be especially considered in the differential diagnoses of
patients presenting with acute deteriorations of their aortic regurgita-
tion (Zhu et al., 2020). Moreover, the dilation of the aortic root com-
ponents that may be caused by a variety of disorders may stretch the
free margins of the aortic leaflet and thus can enlarge the fenestra-
tions earlier present in the commissural zone, create the new stress
fenestration or even cause the detachment of the leaflet from its com-
missure. Furthermore, the presence of the aortic valve fenestrations
may affect the use of surgical techniques targeted at the aortic valve
and hinder or even prevent aortic valve-sparing operations
(David, 2016). Beside these aspects, some case reports and small case
series have also described the coexistences of fenestrations with
other aortic valve-related pathologies, including bi- and quadri-cuspid
aortic valves and/or Down syndrome or Marfan syndrome (Akiyama
et al., 1998; Sylvester, 1974; Yang et al., 2019; Yotsumoto
et al., 2003; Zhu et al., 2020). However, based on our findings that
due to the high prevalence of aortic valve fenestrations in the healthy
population, conclusions based on single case reports should not be
drawn relative to the cause and effect-like coexistences between fen-
estrated leaflets and aortic valve morphological defects or genetic
syndromes.
Although aortic leaflet fenestrations are common, their identifica-
tions with clinical imaging remains challenging. Because of the sizes of
the fenestrations and their locations within leaflets (pericommissural),
even today transthoracic and even transesophageal echocardiography
have limited capabilities to visualize even large fenestrations (Aly
et al., 2020). More often, the presence of ruptured fenestrations
within insufficient aortic valves can be illustrated by echocardiography
as a leaflet prolapse or mobile fibrous strand attached to commissural
region of the given valve (Yang et al., 2019). Also, still today other
radiographic techniques, such as cardiac computed tomography and
magnetic resonance imaging, have elicited low capabilities of routinely
visualizing fenestrated leaflets (due to low spatial resolution) (Tretter
et al., 2021). Unfortunately, in the era of the transcatheter aortic valve
procedures, the presence of fenestrations may bring important new
challenges. It is not difficult to imagine that a coronary guild or pigtail
catheter becoming entangled in the fenestration meshes, which would
make the procedure much more difficult or impossible to perform.
Even the iatrogenic rupture of a fenestration may be expected as the
most severe procedural complication (Algarni et al., 2015). Taking this
into account, awareness relative to anatomical locations, structures,
and functions of aortic leaflet fenestrations should be strengthened
among clinicians.
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DUDKIEWICZ ET AL.
Some potential limitations of our studies should be considered.
Morphometric assessments were performed on autopsied material
fixed in formaldehyde solution, which may be a limitation even though
our previous studies have demonstrated that paraformaldehyde fixa-
tion does not significantly affect the dimensions of human heart tissue
(Hołda et al., 2016, 2018). Furthermore, the Visible Heart® methodol-
ogies employed for human heart reanimation may have resulted in
slight deformities annular shapes and function throughout the cardiac
cycle. Further, functional observations were based on subjective
assessments of the obtained video material by researchers and were
not specifically quantified. Additionally, the relatively small number of
investigated reanimated hearts in the functional part of this study
may have introduced some bias in interpretations. Finally, only hearts
from donors without significant aortic valve diseases were investi-
gated in both parts of the current study; therefore, our study results
may be not valid for patients with aortic valve diseases. Despite these
limitations, it is strongly believed that in the current study, complex
insights relative to the morphometrical and functional analyses of the
aortic valve fenestrations was provided.
5 | CONC LU SIONS
Fenestrations of the aortic leaflets in humans are frequent (43.0%
hearts) subclinical variant of the aortic valve anatomy, and their sizes
may be considered as significant. Overwhelmingly, fenestrations form
clusters and are mainly located at the free edge of the leaflet in the
commissural area. Fenestrations were observed in all age groups, yet
their sizes were observed to increase with age. The most prominent
fenestrations are observed within the aortic left leaflets, followed by
right and noncoronary. Regions of the leaflets with fenestrations pre-
sent, elicited different behaviors during a valve's cardiac cycle, versus
unchanged areas. Our unique anatomical observations of aortic valve
leaflet fenestrations morphometries and functional behaviors should
provide valuable consideration when one is planning and performing
aortic valve interventions.
ACKNOWLEDG MENTS
The authors sincerely thank those who donated their bodies to sci-
ence so that anatomical research could be performed. Results from
such research can potentially increase mankind's overall knowledge
that can then improve patient care. Therefore, these donors and their
families deserve our highest gratitude. We show our gratitude to the
patients and families who have donated their hearts for research, and
to LifeSource (MN, USA) for their assistance in the recovery and
transport of the organs. The Visible Heart® Laboratory was supported
in part by the Institute for Engineering in Medicine, the Lillihei Heart
Institute and through a research contract with Medtronic.
OR CID
Paul A. Iaizzo https://orcid.org/0000-0002-7661-352X
Mateusz Koziej https://orcid.org/0000-0002-2635-0776
Mateusz K. Hołda https://orcid.org/0000-0001-5754-594X

DUDKIEWICZ ET AL.
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How to cite this article: Dudkiewicz, D., Zhingre Sanchez,
J. D., Hołda, J., Bolechała, F., Strona, M., Kopacz, P., Iaizzo,

ska, M. (2023).
P. A., Koziej, M., Hołda, M. K., & Konieczyn
Aortic valve fenestrations: Macroscopic assessment and
functional anatomy study. Clinical Anatomy, 36(4), 612–617.
https://doi.org/10.1002/ca.24002