JIIMS.cdr


54

ORIGINAL ARTICLE

ABSTRACT
Objective: To study the variations in gross appearance of ascending aortic fold, and relationship of vertical
height of middle of fold to vertical height of heart and to the mean width of the fold.
Study Design: This was a cross sectional study.
Place and Duration of Study: Department of anatomy, Rawalpindi Medical College, Rawalpindi, from Jan 2010
to Dec 2010.
Materials and Methods: The present study was carried out on 24 hearts obtained from the dissection room of
Rawalpindi Medical College, Rawalpindi. All the cases cadavers available during the study period were included
in the study. The ascending aorta was studied with respect to its length and presence of fold in each of the
specimens. The direction of the fold was noted for the classic oblique form and other variations.
Results: The fold was present in all the specimens. It was oblique in 13 cases, horizontal in 6, oval in 2, vertical
oblique in 2 and vertical horizontal in 1 individual. The vertical height of middle of fold was inversely proportional
to vertical height of the heart and directly proportional to the mean width of the fold.
Conclusion: The present study provided new dimension and observation that the vertical height of the middle of
fold and vertical height of heart are inversely proportional to each other. Vertical height of the middle of fold and
mean width of the fold are directly proportional to each other.

Keywords: Ascending Aortic fold, Vertical height of heart, Mean width of aortic fold.

of fat was the result of collateral
enlargement of blood vessels in the fat pads

5
to lessen the effect of coronary insufficiency.
It was demonstrated by Woodruff that
opening of vasa vasorum of aorta was

6
present beneath the fat pads. Vasa vasorum
are contained in adventitia of large

7,8
arteries. It was reported by David J.Davis
(1927) that ascending aortic fold was
constant in location, form and size. He
suggested the name of periaortic fat bodies

9
for the fold.  Epicardial fat pad was another
name used by Robertson (1930) for the
ascending aortic fold. He was of the opinion
that the fold carried an arterial network to
the vasa vasorum of aorta and a site of

10
anastomosis between the coronary arteries.
The fold was found by Parke and Michels
(1966) in adults, children and fetuses and
was called by them as aortic ridge. They
proposed that it relieves pressure and

11
friction between aorta and right auricle.  A
relatively recent study was carried out by
G.T Lebona (1993) in South Africa. He
proposed the name of ascending aortic fold.
The fold has not been mentioned in the
recent textbooks of anatomy. He observed
that apart from classic oblique form other

Introduction

The ascending aortic fold was described for
the first time by Rindfleisch (1984) as a
fibrofatty epicardial fold, semilunar in
shape, 1 to 3 cm long, 2 to 5 mm wide and
directed obliquely across the middle of
anterior surface of ascending aorta. He
concluded that the fold enhanced the

1
e l a s t i c i t y o f v i s c e r a l p e r i c a rd i u m .
Epicardium is the visceral layer of
pericardium. Ascending aorta is enclosed in
a sheath of serous pericardium. Serous
pericardium has parietal and visceral layer.
P a r i e t a l l a y e r l i n e s t h e f i b r o u s

2,3
pericardium. Accessory thyroid tissue was
detected by Swarts and Thompson (1911) in

4
sub-epicardial preaortic fat.
The term of periaortic fat pads was used by
Gross (1921) for the ascending aortic fold.
He observed that these fat pads increase
with age and myocardial pathology. He
concluded that this progressive deposition

-------------------------------------------------
Correspondence:
Dr Amer Qayum
Assistant Prof of Anatomy
Rawalpindi Medical College, Rawalpindi
E. mail: Aaau32@gmail.com

A Study of Variations in Human Ascending Aortic Fold
Amer Qayum, Tahzeeb ul Hassan, Tassaduq Hussain



55

varieties of ascending aortic fold also
12,13

exist. Different views were given about
the structure of ascending aortic fold. The
knowledge about the fold was limited.
Moreover no more studies could be found to
confirm or refute the work done by G.T
Lebona, which needs to be studied and
explored more. This inspired me to work for
this difficult task and to conduct the present
study.

This was cross sectional study carried out in
Rawalpindi Medical College from Jan 2010
to Dec 2010.
All the cadavers dissected during this
period were used for this study. For the data
collection a structured questionnaire was
developed mentioning the important
variables about Length, width, position,
type's and shapes/axis of fold etc. Data was
analyzed by using Microsoft Excel and
Statistical package for social sciences
version 17.Mean and standard deviation
were calculated; cross tabs were done and
mentioned in tables and graphs.
The material consisted of 24 hearts obtained
from the dissection hall of Rawalpindi
Medical College, Rawalpindi.
Obese adult, putrefied and macerated
specimens, gross pathological findings like
aortic aneurysms, myocardial infarction and
congenital anomalies were not included.
The ascending aorta was studied with
respect to its length and presence of fold in
each of the specimens. The direction of the
fold was noted for the classic oblique form
and other variations. Mean width of the fold
was calculated by taking the average of
maximum and minimum width in each of
the specimens. The vertical height of the
middle of fold was measured from middle of
its upper border to its lower border. Vertical
height of the heart was measured from
middle of the upper border of fold to the
inferior border of heart. Height of the fold as

Materials and Methods

percentage of height of heart was also
calculated in each of the specimen. A
comparison of the vertical height of the heart
and vertical height of the fold was made in
e a c h o f t h e s p e c i m e n . S i m i l a r l y a
comparison of mean width and vertical
height of the middle of the fold was made.

The ascending aortic fold was present in all
the 24 specimens. It was obliquely oriented
in 13 specimens as shown in figure 1.
Horizontal variety was present in 6
specimens as shown in figure 2. The fold was
oval in 2 hearts as shown in figure 3. In
remaining 3 specimens combination of axis
was observed. It was vertical oblique in 2
specimens as shown in figure 4. Vertical
horizontal form was seen in only 1 heart as
shown in figure 5. The frequency of
variations of ascending aortic fold is shown
in table 1. Length of ascending aorta ranged
between 4.40 to 5.40 cm. The mean length of
ascending aorta came out to be 4.90cm as
shown in table 1. The mean width of the fold
ranged between 0.19 cm and 1.07 cm. The
mean of the mean width was 0.41 cm with
SD of 0.17 as shown in table 1.The vertical
height of the middle of fold ranged between
0.21 cm to 0.82 cm, with mean value of 0.39
and SD of 0.14 as shown in table 1.The
vertical height of the heart ranged between
7.80 cm and 9.82 cm with mean value of 8.66
cm and SD of 0.62 as shown in table 1. Height
of the fold as percentage of height of the
heart ranged from 2.23% to 8.81% with mean
of 4.61% as shown in figure 6 and table 1. The
vertical height of the fold decreased as the
height of the heart increased as shown in
figure 7. The vertical heights of the middle of
fold and mean width of fold generally
remained in the similar ranges as shown in
figure 8.

Results



56

Figure 1: Anterior aspect of ascending aorta
showing oblique type of ascending aortic fold
(yellow arrows). 

Figure 2: Anterior aspect of ascending aorta
showing horizontal type of ascending aortic fold
(yellow arrows).

Figure 3: Anterior aspect of ascending aorta
showing oval type of ascending aortic fold
(yellow arrows).

Figure 4: Anterior aspect of ascending aorta
showing vertical oblique type of ascending
aortic fold (yellow arrows).

Figure 5: Anterior aspect of ascending aorta
showing vertical horizontal type of ascending
aortic fold (yellow arrows)

Figure 6: The height of the fold as percentage
of height of the heart.



57

Table I: Gross parameters of ascending aortic fold



58

Discussion

The present study has shown that the
ascending aortic fold is a constant feature
and confirmed the findings of previous

1,9,11,12
workers. During the present study
mean length of aorta (4.90cm) was
approximately the same as given in

14
literature. Earlier the literature identified
only oblique semilunar form of the
ascending aortic fold. Later on, it was
reported by G.T Lebona that a wide

12,13
variation in gross anatomy of fold exists.
He observed classic oblique form in 51 out of
90 specimens. Horizontal form was seen in
17, vertical form in 5 and oval in 2 hearts. In
the remaining 15 hearts the fold was seen in
the form of a combined axial pattern. It was
horizontal-oblique in 4, vertical-oblique in 6,
vertical-horizontal in 3, vertical-horizontal-
oblique in 1 and oval-oblique in 1. The
present study has confirmed that variations
are present in the gross anatomy of

ascending aortic fold. Classic oblique form
was present in 13 out of 24 hearts. It was oval
in 2 hearts and horizontal in 6 hearts. The
remaining 3 hearts showed a combination of
axis. The fold was vertical-oblique in 2 and
vertical-horizontal in 1 of the hearts.
However the variations noted in the present
study were not as wide as seen by G.T
Lebona in Black South Africans. Thus the
present study is the first to agree with the
work of G.T Lebona. During the present
study it was found that height of the fold as
percentage of the height of heart ranged
from 2.23% to 8.81% with mean value of
4.61%. A trend was noted that as the vertical
height of heart increase there was no
increase in vertical height of middle of fold,
rather it decreased. To our knowledge no
such study has been carried out before this.
The present study provides new dimension 
and observation that the vertical height of
the middle of fold and mean width of the
fold are directly proportional to each other.

1. Daniel A, Anne MB. Dorland's medical
dictionary. 32nd ed.  United States of America.
Elsevier WB Saunder's Company; 2012. p1648.

2. Snell, Richard S. The Thoracic Cavity. In
t h

C l i n i c a l A n a t o m y b y re g i o n s . 9 e d .
Philadelphia: Lippincot Williams and Wilkins,
2012. p95.

3. Chummy S. Sinnatamby. Middle Mediastinum
t h

and heart. 12 ed. London: Churchill
Livingstone Elsevier; 2011. p197.

4. Swarts and Thompson: Aberrant Thyroids in
Pericardium in the Dog. J.M Research 1911; 24:
299.

5. Louis Gross. Age period changes in the blood
supply to the heart and their pathogenic
relations. In: The blood supply to the heart and
its anatomical and clinical aspects. New York:
Paul B.Hoeber; 1921. p109.

6. Woodruff, CE. Studies on the vasa vasorum. Am
J Path1926; 2: 567-75.

7. Anthony L Mescher. The Circulatory System. In
th

Junqueiras Basic Histology. 12 ed. New York.
Mc Graw Hill Companies, 2010, p190.

8. Michael H. Ross & Wojciech Pawlina.

Reference

Figure 7: Scatter graph showing the comparison
of vertical height of the fold and the vertical
height of the heart.

Figure 8: Scatter graph showing the
comparison of vertical height of middle of fold
and its mean width.



59

Cardiovascular System. Text Book and Atlas of
th

Histology 6 ed. Lippincot Williams and
Wilkins; 2011. p417.

9. Davis DJ. The periaortic fat bodies. Archives of
pathology and Laboratory Medicine 1927; 4:
937-42.

10. Robertson H F. The Vascularization of the
epicardial and periaortic fat pads. Am J Path
1930; 6: 209-15.

11. Parke WW & Michels NA. The human aortic
ridge and cushion. Anatomical Record 1966;
154; 185-93.

12. Lebona GT. Morphological variations of the
human ascending aortic fold. J Anat 1993; 182:
275-9.

13. Lebona GT. The presence of paraganglia in the
human ascending arotic fold: histological and
ultra structural studies. J Anat 1993; 183: 35-41.

14. Gerard J. Tortora, Bryan Derrickson. The
Cardiovascular System; Blood Vessels and
Haemodynamics. Principles of Anatomy and

th
physiology. 13 ed. Hoboken Jhon Wiley and

sons. 2011. p831.