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Khalil Fattouch
Patrizio Lancellotti
Mani A. Vannan
Giuseppe Speziale
Editors
123
Advances in Treatments for Aortic Valve and
Root Diseases
Khalil Fattouch • Patrizio Lancellotti
Mani A.Vannan • Giuseppe Speziale
Editors
Advances in Treatments
for Aortic Valve and Root
Diseases
Editors
Khalil Fattouch Patrizio Lancellotti
Department of Cardiothoracic Department of Cardiology
and Vascular Surgery University of Liège
GVM Care and Research, MEH Liège
University of Palermo Belgium
Palermo
Italy Gruppo Villa Maria Care and Research
Anthea Hospital
Mani A. Vannan Bari
Marcus Heart Valve Center Italy
Piedmont Heart Institute
Atlanta, Georgia Giuseppe Speziale
USA Cardiovascular Surgery Department
GVM Care & Research
Anthea Hospital
Bari
Italy
This Springer imprint is published by the registered company Springer International Publishing AG
part of Springer Nature
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
Part I Anatomy
Part II Imaging
v
vi Contents
17 Mini-Sternotomy���������������������������������������������������������������������������������������� 239
Alberto Albertini
18 Right Anterior Mini-Thoracotomy for Aortic Valve Replacement ������ 259
Marco Solinas and Giacomo Bianchi
19 Totally Endoscopic Aortic Valve Replacement (TEAVR) ���������������������� 275
Marco Vola
20 Sutureless Aortic Valve Implantation������������������������������������������������������ 285
Theodor Fischlein and Giuseppe Santarpino
Contents vii
Index������������������������������������������������������������������������������������������������������������������ 413
Part I
Anatomy
The Clinical Anatomy of the Aortic Root
1
Robert H. Anderson, Diane E. Spicer, and Shumpei Mori
1.1 Introduction
The definitive outflow tracts in the postnatal hearts possess three components. These
are the intrapericardial arterial trunks, the arterial roots, and the subvalvar ventricu-
lar outflow tracts. The distal boundary of the aortic root with the intrapericardial
component of the ascending aorta is clearly marked by the sinutubular junction. The
proximal boundary, in contrast, has no direct anatomic substrate. It is represented by
the virtual plane that can be created by joining together the basal attachments of the
moving components of the root. As we will see, the virtual nature of this entrance to
the root creates problems in defining the so-called valvar “annulus”. This is the
more so, since many surgeons consider the semilunar hinges of the moving compo-
nents to represent the “annulus” [1]. This is but one of the issues with nomenclature
which plague the search for consensus when describing the components of the aor-
tic root. As was emphasised by the study group of German cardiac surgeons, the
current situation can be considered as a modern-day “tower of Babel” [1]. In this
chapter, as we describe the anatomical feature of the root, we also seek to provide
solutions to the terminological problems. We emphasise the importance, if we are to
The words we use to describe the parts of the aortic root are equally applicable to
the pulmonary root. They can, by and large, also be used to describe the components
of the atrioventricular valves. This comparison serves also to emphasise some of the
current difficulties. Thus, there are some who seek to differentiate the moving
components of the atrioventricular valves as the leaflets, but to describe the moving
parts of the arterial valves as the cusps. There are multiple reasons why this approach
is less than satisfactory. In the first place, the right-sided atrioventricular valve is
universally called the tricuspid valve, showing that, at some time previously, the
moving parts of this valve, and the mitral valve, with its alternative title of the bicus-
pid valve, were also considered to be “cusps”. This likely reflects the similarity to
the surfaces of the molar and premolar teeth to the surfaces of the closed valves
when viewed from their atrial aspect. The closed surfaces of the arterial valves also
present a similar appearance when viewed from their ventricular aspect (Fig. 1.1a).
It is very unusual nowadays, however, for the arterial valves to be assessed from this
aspect. The surgeon tends to view the valves from the arterial aspect. For morpholo-
gists, they are typically viewed, and interrogated, in opened fashion (Fig. 1.1b).
Assessment from the opened viewpoint then emphasises the inadequacy of using
the word “cusp” to describe the moving components. When defined literally, a
“cusp” is a point or elevation, or the crossing point of two curves. As is seen in
Fig. 1.1b, the hinges of the curved moving components cross at the sinutubular
junction. If defined literally, therefore, this crossing point should be recognised as
the “cusp”. Instead, these distal attachments of the moving components at the sinu-
tubular junction are universally described as the valvar commissures (Fig. 1.1b).
This usage then creates still further problems in terms of naming, since for anato-
mists a “commissure” is the line of union of adjacent structures, as seen in the lips
or the eyelids. If defined in anatomical fashion, therefore, it would be the zones of
apposition of the moving components between their peripheral attachments at the
sinutubular junction and the centroid of the valvar orifice which would be called the
commissures (Fig. 1.2). It is most unlikely that clinicians will ever desist from nam-
ing the peripheral attachments as the commissures, so we follow this conventional
1 The Clinical Anatomy of the Aortic Root 5
Mitral valve
Non–adjacent aortic leaflet
Fig. 1.1 The images show the problems with the use of “cusp” to describe the moving parts of the
aortic root. If defined literally, a cusp is a point or elevation, or the crossing point of two curves.
When seen in closed position (Panel a), there is a resemblance between the ventricular margins of
the moving parts and the surface of a molar or premolar tooth, these surfaces also described as
cusps. When seen in the open position, however, (Panel b), there is no resemblance of the moving
parts to the surfaces of the teeth. Instead, the crossing points of their semilunar hinges become
evident at the sinutubular junction (white ovals on broad dashed black line). These points, however,
are traditionally described as the valvar commissures (see Fig. 1.2). Note the area of fibrous conti-
nuity between the moving components of the aortic and mitral valves, shown as a black dotted line
in panel a, and the virtual nature of the entrance to the root shown as the black dotted line in Panel
b. Note also the fibrous triangles separating the ventricular aspects of the semilunar moving com-
ponents (black arrows in panel b). The authors retain their intellectual copyright in the images
from which these figures were prepared
Fig. 1.2 The images show the arterial aspect of the closed aortic valve as seen in an anatomical
specimen (Panel a) and a “fish-eye” view of a reconstructed computed tomographic dataset
obtained from a patient undergoing analysis of coronary arterial disease. The stars show the
peripheral attachments of the semilunar hinges of the moving components of the root at the sinu-
tubular junction. These are known traditionally as the commissures. When defined anatomically,
however, a “commissure” is the zone of apposition between two adjacent parts, as shown by the
white arrows. Since it is unlikely that “commissure” will be used to describe anything other than
the peripheral attachments of the hingelines, we will describe the junctional areas as the zones of
apposition. As is seen from both panels, these fit snugly together when the valve is competent. The
authors retain their intellectual copyright in the images from which these figures were prepared
Fig. 1.3 The images show the optimal convention for naming the sinuses of the aortic root. The two
sinuses adjacent to the pulmonary root give rise to the coronary arteries. The root is viewed from the
arterial aspect in the specimen shown in panel a. The third sinus, which does not usually give rise to
a coronary artery, is not adjacent to the pulmonary root. It can, however, on rare occasions give rise
to a coronary artery. We prefer, therefore, to describe the sinus as being non-adjacent. The image
obtained by virtual dissection of a computed tomographic dataset obtained from a patient undergo-
ing analysis for coronary arterial disease (Panel b), orientated to match the image shown in panel a,
reveals the presence of the small crescents of myocardium incorporated at the base of the two
sinuses which give rise to the coronary arteries (white double headed dotted arrows). The authors
retain their intellectual copyright in the images from which these figures were prepared
1 The Clinical Anatomy of the Aortic Root 7
greater in the right coronary than the left coronary sinus (Fig. 1.3b). There is no
myocardium, however, incorporated at the base of the third aortic sinus, which is
opposite to the pulmonary trunk (Fig. 1.3a). The leaflet of the aortic valve supported
by this sinus is in fibrous continuity with the aortic, or anterior, leaflet of the mitral
valve. In most instances, this sinus is called the non-coronary sinus. This is usually
an appropriate designation. Very rarely, however, a coronary artery can take its ori-
gin from this sinus [5]. In such circumstances, it makes no sense to name the sinus
as being “non-coronary”. We prefer, therefore, to identify the sinus as being non-
adjacent (Fig. 1.3a).
When we assess the aortic root in opened fashion (Fig. 1.1b), we then recognise
further components of the root which, until relatively recently, have received scant
attention from clinicians. These are the interleaflet triangles [6]. Part of the subval-
var component of the root, and hence part of the left ventricular cavity, they are
distal to the virtual basal plane created by joining together the proximal attachments
of the semilunar leaflets. They separate, furthermore, the cavity of the left ventricle
from either the pericardial space, or the tissue plane between the aortic root and the
subpulmonary infundibulum. We will describe, in a subsequent section, the rela-
tionships of these triangles in detail, since in many ways an appreciation of their
location is the key to understanding the overall valvar anatomy [6]. As can be seen
from Fig. 1.1b, nonetheless, the triangles occupy the spaces within the root located
on the ventricular aspects of the semilunar hinges of the leaflets. It is these semilu-
nar hinges, therefore, which mark the haemodynamic ventriculo-arterial junction.
They separate the parts of the root which, during catheterisation procedures, register
aortic as opposed to left ventricular pressures. These haemodynamic ventriculo-
arterial junctions, however, are markedly different from the anatomic junctions
between the proximal extent of the arterial walls of the valvar sinuses and the sup-
porting ventricular structures [7]. As already explained, it is because the semilunar
hinges cross this anatomic ventriculo-aortic junction that the crescents of myocar-
dium are incorporated at the bases of the two sinuses giving rise to the coronary
arteries (Fig. 1.3b). And, as also explained, the virtual basal plane marking the
entrance of the root is constructed by joining together the proximal attachments of
the leaflets.
It is the virtual nature of this plane that creates the perhaps biggest persisting
problem in reaching consensus on naming the components of the root, namely the
nature of the so-called “annulus”. In the sense that the boundaries of the virtual
plane created by joining together the nadirs of the semilunar hingelines form a
little ring, there is justification in taking the basal ring to represent the valvar
annulus. This is the approach taken by clinicians when measuring the dimensions
of the root. In contrast, many, but not all, surgeons consider the semilunar hinges
of the leaflets to represent the valvar annulus [1]. When reconstructed, however,
these hingelines take the form of a coronet rather than a little ring (Fig. 1.4). The
semilunar hingelines also extend through the full length of the root, with the
dimensions of their diameters varying according to whether measured at the level
of the virtual basal plane, the mid-sinusal level, or at the sinutubular junction
(Fig. 1.5). For better or worse, furthermore, it is the diameter of the virtual basal
plane that is measured by echocardiographers and angiographers when account-
ing for the valvar “annulus”. This, therefore, is the plane that should probably now
8 R.H. Anderson et al.
Central point
of closure
Sinutubular
junction
Effective height
Mid–sinusal
diameter
Geometric height
Sinutubular
junction
a b
Fig. 1.5 The image in Panel a shows a section taken through a computed tomographic dataset
obtained from an individual undergoing assessment for suspected coronary arterial disease. The
section is cut through the nadirs of the right coronary and the non-adjacent aortic valvar sinuses. It
shows how the dimensions of the root vary in terms of its distal, middle, and proximal boundaries,
with the proximal border formed by joining together the attachments of the hinges of the valvar
leaflets (See also Figs. 1.6 and 1.7). The solid and dotted double-headed red arrows show the so-
called effective and geometric heights of the valvar leaflets. Note that the line of closure of the
leaflets is no more than half way up the height of the arterial root. This is confirmed by the recon-
structed images shown in Panel b. The central point of coaptation of the closed leaflets is apprecia-
bly proximal to their peripheral attachment at the sinutubular junction. The authors retain their
intellectual copyright in the images from which these figures were prepared
1 The Clinical Anatomy of the Aortic Root 9
26.4 mm
16.7 mm
26.2 mm
21.9 mm
23.9mm 18.9 mm
be taken as the clinical annulus [8], although it must be remembered that many
surgeons will still describe the valvar coronet as the surgical annulus [9]. A case
can be made, therefore, for distinguishing between the surgical and the echocar-
diographic annuluses [10].
Acceptance that the virtual basal plane represents the echocardiographic annu-
lus, nonetheless, is not without its own problems. This is because, when measured
at mid-sinusal level, or at the sinutubular junction, the aortic root is more-or-less
circular, and there is little difference in the dimensions of its diameters (Compare
Figs. 1.6 and 1.7). This is not the case when assessing the shape of the virtual basal
plane. Rather than being circular, it is decidedly ovoid. Hence, there are potentially
significant differences when assessing the root in terms of measurements taken from
the nadirs of the valvar leaflets as opposed to planes that bisect the root (Fig. 1.8).
Because of these potential problems, it is more sensible nowadays to measure the
area of the entrance to the root using three-dimensional techniques (Fig. 1.5), rather
than seeking to use a solitary measurement to represent the valvar “annulus”
(Fig. 1.8). It is then also necessary to recognise that, when the valvar leaflets are in
their closed position (Fig. 1.2), the central point of coaptation is no more than half-
way up the length of the root (Fig. 1.5). This is the area recognised by surgeons as
the effective height of the leaflets, to be distinguished from their geometric height,
which is achieved when the leaflets are lying in their open position within the valvar
sinuses [11].
10 R.H. Anderson et al.
18.9 mm
16.7 mm
a b
Fig. 1.7 The images show two sections taken through the computed tomographic dataset used to
produce Figs. 1.5 and 1.6. Panel a shows a parasternal long axis cut taken through the nadirs of the
right coronary and non-adjacent aortic valvar sinuses. It is contrasted, in panel b, with a cut taken
from the nadir of the right coronary sinus to the zone of apposition between the left coronary and
non-adjacent aortic valvar leaflets, this plane bisecting the aortic root. The cut from nadir-to-nadir
underestimates the diameter of the root by one-eighth. The authors retain their intellectual copy-
right in the images from which these figures were prepared
Fig. 1.8 The panels illustrate the potential problems in providing accurate measurements of the
virtual basal plane, which is the “echocardiographic annulus”, when assessing the dimensions
from nadir to nadir of the valvar leaflets, rather than taking a measurement that bisects the aortic
root. The upper left hand panel shows the arrangement as seen from the ventricular base, whereas
the lower left panel shows a virtual dissection as viewed from the atrial aspect. The red and yellow
arrows show dimensions comparable to those shown in Figs. 1.6 and 1.7. The authors retain their
intellectual copyright in the images from which these figures were prepared
1 The Clinical Anatomy of the Aortic Root 11
Another of the problems that continue to plague a full understanding of the anatomy
of the aortic root is the ongoing penchant of anatomists and cardiologists to describe
the heart in so-called “Valentine” location, as if removed from the body and posi-
tioned on its apex, rather than as it lies in the body. There is no excuse now for
continuing to use this approach to naming components of the heart. Not only does
it break the cardinal rule of human anatomy, namely that all structures within the
body should be named using the so-called “anatomical position”, with the subject
standing upright and facing the observer, but the anatomy itself is now increasingly
demonstrated in the clinical setting using three-dimensional techniques which show
the heart in its bodily location. The most egregious example of the use of the
Valentine approach is the naming of the coronary artery that is inferior and interven-
tricular as being posterior and descending (Fig. 1.9) [12]. Less obvious is the nam-
ing of the aortic valvar sinuses. If designated as being right coronary, left coronary,
and non-adjacent, the constraints of the Valentine approach are removed, since these
terms themselves do not depend on the relationships between the sinuses and the
bodily coordinates. The right coronary sinus, however, is located anteriorly relative
to the two other sinuses when the heart is normally located, with the non-adjacent
and left coronary sinuses being positioned side-by-side, with the non-adjacent sinus
to the right (Fig. 1.9).
Non-adjacent sinus
Fig. 1.9 The aortic valvar sinuses have been reconstructed from a computed tomographic dataset
prepared from an individual undergoing assessment for suspected coronary arterial disease. They
are shown as seen from the front. The right coronary aortic sinus, shown in yellow, is positioned in
front of the non-adjacent, and left coronary sinuses, shown in green and red, respectively. Note that
the so-called “posterior descending artery”, which in this individual arises from the circumflex
artery, is interventricular and located inferiorly. The authors retain their intellectual copyright in
the image from which this figure was prepared
12 R.H. Anderson et al.
Assessment of the cardiac base from the atrial aspect shows how the aortic root
forms its centrepiece (Fig. 1.10). Viewing the cardiac silhouette from the front con-
firms the central location of the root, positioned as it is at the junction of the left
ventricular outflow tract and the intrapericardial component of the ascending aorta
(Fig. 1.11). The current ability to separate the components of the heart by interroga-
tion of computed tomographic datasets confirms that the so-called “right” chambers
of the heart are, in reality, located anteriorly relative to their presumed left-sided
counterparts. The aortic root is wedged between the anteriorly positioned infun-
dibulum of the right ventricle and the anterior attachment of the atrial septum
(Fig. 1.10). Unlike the right ventricle, which possesses a completely muscular out-
flow tract, the infundibulum, which lifts the leaflets of the pulmonary valve away
from the cardiac base, the outflow tract of the left ventricle is relatively short, and
has no discrete anterior boundary. Its posterior boundary is formed by the extensive
area of fibrous continuity between the leaflets of the aortic and mitral valves. It is the
attachments of this so-called aortic-mitral curtain which anchor the aortic and mitral
valves to the roof of the left ventricle (Figs. 1.12 and 1.13). When the left ventricle
is opened, it is easier to recognise the thickenings of both ends of the aortic-mitral
curtain. These areas are the so-called right and left fibrous trigones. As shown in
Figs. 1.12 and 1.13, it is the attachment of the trigones to the summits of the
Pulmonary root
Extrapericardial aorta
Intrapericardial aorta Intrapericardial aorta
Pulmonary trunk
Aortic root
Right atrium
Outflow tract
Right ventricle
a Left ventricle
b
Fig. 1.11 The images are prepared using a computed tomographic dataset obtained from an indi-
vidual undergoing assessment for suspected coronary arterial disease. The images in panel a shows
the extent of the pericardial cavity, which is separating the intra-and extrapericardial components of
the ascending aorta. The dataset has been coloured so as to show the subvalvar component of the left
ventricle. In panel b, the components of the so-called right heart have been added. As can be seen, in
reality the right heart chambers are anterior to their supposedly left counterparts, with the aortic root
wedged between the infundibulum of the right ventricle and the posteriorly located left atrium. The
authors retain their intellectual copyright in the images from which these figures were prepared
ventricular walls which anchors the combined valvar unit within the base of the left
ventricle. The right fibrous trigone itself is then usually in fibrous continuity with
the membranous part of the ventricular septum. The septal component then forms
the right wall of the proximal part of the aortic root and the right-sided cardiac
chambers (Fig. 1.12). The conjoined structure formed centrally within the cardiac
base from the right trigone and the membranous septum is also the strongest part of
the insulating plane between the atrial and ventricular chambers. It is the so-called
central fibrous body (Fig. 1.14). The membranous septum itself is also continuous
distally with the fibrous tissue that fills the gap found on the ventricular aspect of the
right aortic and non-adjacent valvar sinuses as the hinge lines of the leaflets sup-
ported by these sinuses come together at the sinutubular junction. Such areas of
fibrous tissue are also found on the ventricular aspect of the junctional zones
between the other valvar sinuses. It is an appreciation of the locations and the rela-
tionships of these areas of fibrous tissue separating the distal attachments of the
valvar sinuses, the so-called interleaflet fibrous triangles [6], that underscores the
overall understanding of the anatomy of the aortic root.
It is the basal continuation of the membranous part of the ventricular septum that
constitutes the largest of the triangles. As already shown and discussed, the
14 R.H. Anderson et al.
Mitral
valve
Tricuspid
valvar
orifice
Non-adjacent leaflet
Fig. 1.12 The heart has been sectioned across the short axis of the ventricular mass, and is
viewed from the ventricular apex. The image shows the attachments of the aortic mitral curtain
(dotted black line) through the right and left fibrous trigones (black open triangles) to the roof of
the left ventricle. Note that there is an inferior extension from the subvalvar outflow tract that
interposes between the inferior part of the muscular ventricular septum and the leaflets of the
mitral valve. In consequence, the leaflets of the mitral valve are hinged from the ventricular sep-
tum only towards the crux of the heart (white star with red borders). The space between the sep-
tum and the valvar leaflets (red arrow) is known as the postero-inferior diverticulum of the
outflow tract (See Fig. 1.13). The authors retain their intellectual copyright in the image from
which this figure was prepared
membranous septum itself separates the medial wall of the aortic root from the
right-sided heart chambers (Fig. 1.12). It is the attachment of the hinge of the septal
leaflet of the tricuspid valve to its right side that separates the septum into its atrio-
ventricular and interventricular components. Viewing the area from the right side in
a virtual dissection shows how the attachment of the inner heart curvature, known
as the ventriculo-infundibular fold, separates the membranous septum from the
apex of the interleaflet triangle. The two components of the membranous septum,
separated from each other by the hinge of the septal leaflet of the tricuspid valve, are
obviously inside the heart. The interleaflet triangle, in contrast, separates the most
distal part of the left ventricular outflow tract, within the aortic root, from the right
side of the transverse pericardial sinus. The right coronary artery runs through this
space as it extends from its sinusal origin to reach the right atrioventricular groove
1 The Clinical Anatomy of the Aortic Root 15
Infundibulum
Mitral orifice
Right atrium
Right atrium
Mitral orifice
Coronary sinus
a b Inferior diverticulum
Fig. 1.13 The images are prepared by virtual dissection of a computed tomographic dataset
obtained from an individual undergoing assessment for suspected coronary arterial disease. They
are cuts through the cardiac base, viewed from the ventricular apex, and replicate the image pre-
pared from a specimen as shown in Fig. 1.12. Panel a shows how the aortic root is positioned
between the atrial chambers posteriorly and the infundibulum of the right ventricle anteriorly. The
cut is taken apical to the roof of the left ventricle, which is formed by fibrous continuity between
the leaflets of the aortic and mitral valves. Panel b is prepared by angling the section plane so as to
show that the postero-inferior extension of the left ventricular outflow tract, which interposes
between the mitral valvar orifice and the inferior part of the muscular ventricular septum. The
authors retain their intellectual copyright in the images from which these figures were prepared
(Fig. 1.15). This relationship to the rightward margin of the transverse sinus is well
demonstrated by removing the interleaftet triangle in the autopsied heart, and again
viewing the specimen from the right side. The dissection in the autopsied heart
(Fig. 1.16a) confirms the location of the triangle of Koch as shown by the virtual
dissection, and again shows the landmarks that permit prediction of the course of
the atrioventricular conduction axis, a feature of great surgical significance.
Sectioning a virtual dataset then shows the relationships between the fibrous trian-
gle and membranous septum to the extracardiac and intracardiac spaces, respec-
tively (Fig. 1.16b).
The triangle that fills the space on the ventricular aspects of the two aortic valvar
sinuses that support the coronary arteries is the smallest of the three triangles. It
separates the distal extent of the aortic root from the tissue plane that, in turn, is
located between the anterior aspect of the root and the free-standing muscular sub-
pulmonary infundibulum (Fig. 1.17). The third triangle, filling the space between
the ventricular aspects of the left coronary and non-adjacent aortic sinuses, is con-
tinuous apically with the extensive area of fibrous continuity which forms the aortic-
mitral curtain (Fig. 1.13). This triangle again separates the distal extent of the aortic
16 R.H. Anderson et al.
Mitral valve
Fig. 1.14 The aortic root has been opened through a cut across the left coronary aortic sinus,
and is viewed from the front. The aortic-mitral curtain, formed from fibrous continuity between
the aortic leaflet of the mitral valve, the non-adjacent leaflet of the aortic valve, and part of the
left coronary aortic valvar leaflet, forms the roof of the left ventricle. The ends of the area of
fibrous countinuity (dashed black line) are thickened to form the right and left fibrous trigones
(black open triangles). The right trigone is continuous in the medial wall of the aortic root with
the membranous component of the ventricular septum (red triangle), which in turn is continuous
with the fibrous interleaflet triangle interposed between the right coronary and the non-adjacent
aortic valvar sinuses (green triangle). Note the continuity of the interleaflet triangle between the
non-adjacent and the left coronary aortic sinuses (yellow triangle) with the aortic-mitral continu-
ity. Note also the shorter interleaflet triangle (blue triangle) between the two coronary aortic
sinuses. It is only the two leaflets supported by the sinuses giving rise to the coronary arteries
that also have attachment to the left ventricular muscular walls (blue and yellow dashed double
headed arrows). The authors retain their intellectual copyright in the image from which this
figure was prepared
root from the transverse sinus of the pericardial cavity. Due to its more posterior
location, however, this triangle is related to the middle component of the transverse
pericardial sinus. It is the anterior interatrial groove that forms the posterior bound-
ary of the pericardial sinus in this location, with the atrial septum and the oval fossa
directly behind the atrial walls (Fig. 1.18). Bachmann’s bundle, made up of the
aggregated cardiomyocytes that preferentially conduct the cardiac impulse from the
sinus node to the left atrium, extends through these atrial walls.
The location of the triangles can be appreciated by taking histological sections
through the aortic root at mid-sinusal level (Fig. 1.19a) and at the level of the
1 The Clinical Anatomy of the Aortic Root 17
Vent-inf. fold
Medial PM
Interventricular MS
Oval fossa
Atrioventricular MS
Coronary sinus
Fig. 1.15 The virtual dissection is prepared from a computed tomographic dataset obtained from
an individual undergoing assessment for suspected coronary arterial disease. It shows the bound-
ary between the right coronary and the non-adjacent aortic valvar sinuses as viewed from the right
side. Note how the ventriculo-infundibular (Vent-inf.) fold separates the interleaflet triangle, which
is outside the heart, from the membranous septum. It is the septal leaflet of the tricuspid valve that
divides the membranous septum (MS) into its atrioventricular and interventricular components,
with the hinge line continuing inferiorly to form the anterior boundary of the triangle of Koch,
which is shown by the white dotted lines. The white star with red borders show the location of the
atrioventricular node at the apex of Koch’s triangle, with the red dotted line showing the site of the
atrioventricular conduction axis, with the right bundle branch emerging in the right ventricle
beneath the origin of the medial papillary muscle (PM). The authors retain their intellectual copy-
right in the image from which this figure was prepared
membranous septum virtual basal plane (Fig. 1.19b). The overall relationship of the
root is then better demonstrated by interrogation of datasets prepared during life
using multidetector computed tomography. A section from such a dataset taken
through the cardiac base shows the root sandwiched between the atrial chambers
and the infundibulum of the right ventricle (Fig. 1.20a). By combining the informa-
tion obtained with sectioning the different levels of the root (Fig. 1.19), we can then
construct a cartoon showing the location of the sinuses as seen attitudinally, empha-
sising the location of the support provided by the underlying venticular compo-
nents, with only a small part of the basal circumference being muscular, the larger
parts being fibrous (Fig. 1.20b—compare with Fig. 1.19).
18 R.H. Anderson et al.
Right atrium
Medial PM
Aortic-mitral curtain
a Membranous septum
b
Fig. 1.16 The dissection shown in Panel a is made by removing the interleaflet triangle that sepa-
rates the right coronary and non-adjacent aortic valvar sinuses, along with the portion of the ven-
triculo-infundibular fold adjacent to the atrioventricular junction so as to reveal the interventricular
component of the membranous septum. The heart is then viewed from the right side. The dotted
black lines show the location of the triangle of Koch, with site of the atrioventricular node marked
by the white star with red borders (compare with Fig. 1.15). The red dotted line shows the course
of the atrioventricular conduction axis, with the right bundle branch tracking towards the medial
papillary muscle (PM). The section in panel b is a long axis section through the interleaflet triangle
(double headed red arrow) and the membranous septum (double headed yellow arrow). Note that
the fibrous interleaflet triangle separated the distal extent of the aortic root from the transverse
pericardial sinus. The authors retain their intellectual copyright in the images from which these
figures were prepared
Right coronary artery Left coronary artery Right coronary sinus Non-adjacent sinus
Infundibulum
Infundibulum
Membranous septum
Fig. 1.17 The dissection shown in Panel a is made by first removing the pulmonary valve and its
supporting free-standing infundibular sleeve from the base of the heart, and then removing the
fibrous interleaflet triangle interposed between the right and left coronary aortic valvar sinuses.
Note the location of the first septal perforating artery. The image in panel b comes from a comput-
erised tomographic dataset, and shows the relationship between the anterior wall of the aortic root
in the area of the interleaflet triangle and the subpulmonary infundibulum. The authors retain their
intellectual copyright in the images from which these figures were prepared
1 The Clinical Anatomy of the Aortic Root 19
Left atrium
Transverse sinus
Anterior
interatrial fold
Aortic-mitral curtain
a b
Fig. 1.18 The dissection in Panel a is made by removing the fibrous interleaflet triangle inter-
posed between the non-adjacent and left coronary aortic valvar sinuses, and photographing the
aortic root from behind. Bachmann’s bundle runs through the anterior interatrial fold. Panel b
shows how the interleaflet triangle (double headed red arrow) separates the distal extent of the
aortic root from the transverse pericardial sinus. The section is viewed from the right side. The
authors retain their intellectual copyright in the images from which these figures were prepared
Pulmonary
valve
Right coronary
aortic sinus
Aortic root
Left
coronary
aortic sinus
Non-adjacent
aortic sinus
Aortic-mitral curtain
a b Atrial septum
Fig. 1.19 The sections are taken through a human aortic root sectioned in its short axis. Panel a
is at mid-sinusal level, and shows the interleaflet triangles separating the ventricular aspect of the
root from extracardiac tissues. The black arrow with green borders shows the basal part of the
triangle continuous with the membranous septum, as revealed by panel b, which is taken closer to
the ventricular apex. This panel shows how the hinge of the septal leaflet of the tricuspid valve
separates the membranous septum into its atrioventricular (dotted double headed black arrow) and
interventricular (solid double headed black arrow) components. The black arrow with blue bor-
ders shows the triangle separating the root from the subpulmonary infunbibulum, while the black
arrow with yellow borders shows how the triangle between the non-adjacent and left coronary
aortic sinuses is continuous apically with the aortic-mitral curtain. The images are created using
original material prepared by Professor Nigel Brown, St George’s Medical University, and are
reproduced with his kind permission. Professor Brown retains his intellectual copyright in the
images from which the figures were prepared
20 R.H. Anderson et al.
Aortic root
Right atrium
Fig. 1.20 The image obtained by sectioning the computed tomographic dataset (Panel a), viewed
from the ventricular apex in attitudinally appropriate fashion, shows the central location of the
root, with the atrial chambers posterior and the infundibulum of the right ventricle to the front. The
cartoon shown in Panel b then combines the information regarding the relationships of the differ-
ent parts of the root. The black arrows with coloured borders show the locations of the three inter-
leaflet fibrous triangles (Compare with Fig. 1.19). The authors retain their intellectual copyright in
the images from which these figures were prepared
As shown in Fig. 1.4, reconstruction of the semilunar hinges of the aortic valvar
leaflets produces a coronet-like configuration. It is the remnants of these attachment
of the leaflets within the root, when the leaflets themselves have been removed dur-
ing replacement of the aortic valve, that surgeons use to anchor the sutures used to
secure the placement of valvar prostheses (Fig. 1.21). It is, presumably, for this
reason that many surgeons continue to describe these lines of attachment as the
valvar “annulus”. There is, however, no specific anatomic structure forming the
alleged annulus over and above the attachment of the leaflets to the supporting
structures. The semilunar lines of attachment mark the haemodynamic ventriculo-
arterial junction, but they cross the anatomic ventriculo-arterial junction. It is the
extent of the overall attachments of the leaflets, furthermore, which defines the
extent of the root. As described in the previous section, the interleaflet triangles
separate the tips of the valvar hinges as they come together at the sinutubular junc-
tion. The locations of these spaces between the sinuses can then be used as sites of
incision to enlarge the congenitally narrowed root. Thus, it is incisions made through
the interleaflet triangle that separates the non-coronary and the left coronary aortic
sinuses, continuing proximally into the aortic-mitral curtain, which provides the
substrate for the Nicks-Manougian approach to enlargement of the root [13].
Incisions through the interleaflet triangle separating the right and left coronary aor-
tic sinuses, continuing anteriorly into the subpulmonary infundibulum, underscore
1 The Clinical Anatomy of the Aortic Root 21
Left
coronary
sinus
Mitral valve
Fig. 1.21 The dissection is made by opening the aortic root through the left coronary aortic sinus,
and removing the leaflets of the aortic valve. This reveals the semilunar valvar hinges, described by
many cardiac surgeons as the valvar “annulus”. Note that the nadirs of the hinges of the leaflets
guarding the sinuses giving rise to the coronary arteries extend proximally beyond the anatomic
ventriculo-arterial junction so that crescents of myocardium are incorporated within the bases of
the sinuses (white star and white arrow with red borders). The red dotted line shows the proximal
extent of the atrioventricular conduction axis and the left bundle branch (see also Fig. 1.22). The
authors retain their intellectual copyright in the image from which this figure was prepared
the Rastan-Konno approach. It is not possible, however, to enlarge the root through
the triangle between the right coronary and the non-adjacent aortic sinuses. This is
because the membranous septum forms the base of this triangle, and the atrioven-
tricular conduction axis penetrates through the atrioventricular component of the
septum. This anatomy itself, of course, is of major surgical significance. It is now
also of major concern to interventional cardiologists, since bundle branch block is a
well-recognised complication of transcutaneous insertion of aortic valvar prosthe-
ses [14]. So as to appreciate the adjacency of the conduction axis to the valvar
structure, we cannot do better than consult the original cartoon prepared by Tawara
[15] when he first described the location of the conduction axis (Fig. 1.22). As can
be seen from his reconstruction, the fan formed by the fascicles of the left bundle
branch descends onto the smooth left ventricular septal surface just beneath the
nadir of the hinge of the right coronary aortic leaflet. It is this relationship that pro-
vided the necessary information for the interventional cardiologist so as to avoid
iatrogenic disturbances of rhythm [14]. For the cardiac surgeon, providing that
sutures are placed within the remaining semilunar hinges of the valvar leaflet during
valvar replacements, there should be no danger of damaging the components of the
atrioventricular conduction axis.
22 R.H. Anderson et al.
Conclusion
The aortic root is the central part of both the heart and the left ventricular outflow
tract. It is delimited by the semilunar lines of attachment of the valvar leaflets.
These leaflets are suspended predominantly from the aortic valvar sinuses of
Valsalva. The most proximal attachments of the two leaflets supported by the
sinuses which give rise to the coronary arteries, however, cross the anatomic ven-
triculo-arterial junction. This means that small crescents of myocardium are
incorporated as the bases of both these sinuses. Three-dimensional reconstruction
of the overall arrangement of the valvar hinges produces a coronet-like configura-
tion. It is the hinges that are described by some cardiac surgeons as the valvar
annulus. Clinical diagnosticians, in contrast, tend to describe the diameter of the
virtual plane constructed by joining together the nadirs of attachment of the leaf-
lets as the “annulus”. There is no anatomic structure corresponding to this plane.
The dimensions of the root, furthermore vary markedly not only according to the
depth measurements are taken within the root, but also depending on whether they
are taken from the nadirs of adjacent leaflets or by bisecting the root. These vari-
ous discrepancies emphasise the importance of distinguishing between the surgi-
cal and clinical annuluses. They also indicate that appropriate measurement
should take into account the full extent and configuration of the root.
References
1. Sievers HH, Hemmer G, Beyersdorf F, Moritz M, Moosdorf R, Lichtenberg A, et al. The every-
day used nomenclature of the aortic root components: the Tower of Babel? Eur J Cardiothorac
Surg. 2012;41:478–82.
1 The Clinical Anatomy of the Aortic Root 23
„Die is toch zoo moeilijk niet te kennen, als men eenige keeren hier is
geweest.”
„Omdat ik hier altijd heen ging, als jij je elders bezighield, met fietsen,
roeien, tennissen!”
Lord Lister en Charly Brand waren dien middag naar het Rijksmuseum
gegaan. Ze hadden langen tijd doorgebracht in de Nachtwachtzaal en ook
had Raffles zich bijzonder geïnteresseerd voor de Lombokschatten, die in
een aantal vitrines lagen ten toon gesteld.
„Kom, Edward,” drong Charly aan, „ik ben doodmoe, laat ons in Trianon
een kop thee gaan drinken. Of willen we naar huis gaan?”
„Neen, Charly, ik blijf nog een beetje ronddolen door al die kleine en groote
zalen vol kunstschatten, die zulke onmetelijke sommen
vertegenwoordigen. Je kunt gerust heengaan, als het je begint te
vervelen.”
„De Avondschool”, van Gerard Dou was, met lijst en al, uit het
Rijksmuseum verdwenen.
De kranten, tuk op een schokkend nieuwtje, plozen het geval uit en het
was inderdaad grappig, na te gaan, welke veronderstellingen werden
geuit.
Dat was wel een groote teleurstelling voor de politiemannen niet alleen,
maar ook voor de kunstminnaars, de stedelijke autoriteiten en de
krantenmenschen.
De Groote Onbekende was dien middag thuisgebleven. Hij had, aldus had
hij ten minste zijn jongen secretaris verteld, een lichte vermaning van
hoofdpijn. Daarom had hij het beter gevonden, na den lunch wat rust te
nemen en, na een paar aspirine-poeders te hebben geslikt, had John C.
Raffles zich uitgestrekt op den divan om wat te gaan rusten.
Bij Charly’s woorden keek hij op uit het tijdschrift, dat hij zat door te
bladeren.
Zijn gelaat was kalm als steeds en zijn bruine oogen keken den jongen
Brand vriendelijk aan.
„Maar Charly,” sprak hij, „waarom zouden de Hollanders ook niet eens
warm kunnen loopen? Kijk nou eens naar ons eigen volkje. Het Engelsche
ras is wel het flegmatieke bij uitnemendheid. En heb je nooit in de
Londensche club de heetste woordenwisselingen meegemaakt?”
Toen, met een voor hem zéér ongewone belangstelling, vroeg hij zijn
secretaris:
„O, van alles. Je hadt het moeten hooren, Edward, hoe opgewonden ze
waren en welke weddenschappen ze zooal hebben aangegaan.”
„Ja, ik heb een plannetje, boy, een héél mooi plannetje! En er is alle kans
op, dat het zal slagen!”
„Ik mag ’t lijden,” zuchtte Charly, „want ik heb ’t vandaag al met James aan
den stok gehad over de betaling van onze laatste bezending champagne.”
„Edward heeft weer een van z’n overmoedige buien. Ik zal James
vooreerst dat bevel nog maar niet overbrengen.” [22]
[Inhoud]
VIJFDE HOOFDSTUK.
De schuilplaats van de „Avondschool”.
Tot de personen, die het meest onder den indruk waren van den diefstal in
het Rijksmuseum behoorde zeker wel Jan Heemberg, die het prachtige
huis bewoonde aan de Heerengracht te Amsterdam.
Hij was den vorigen avond zeer laat thuis gekomen van een souper bij een
zijner vrienden en had ’s morgens een gat in den dag geslapen.
„Een schilderij van zoo groote waarde gestolen! Een van onze meest
beroemde meesterwerken uit het Rijksmuseum ontvreemd!”
Telkens herhaalde hij het weer tot zichzelf en nogmaals las hij, wat de
krant ervan wist te vertellen.
Haastiger dan anders gebruikte hij zijn ontbijt; toen kleedde hij zich om uit
te gaan.
Het was nog erg vroeg, misschien vond hij er nog niemand, maar komaan,
het was te probeeren.
Hij verscheen daar anders nooit op dit gedeelte van den dag en verbaasd
keek hij op, toen hij in de leeszaal reeds verscheiden plaatsen bezet vond.
Hij liep deze zaal door en kwam door de zich geruischloos openende
donkergroene deur in de daaraan grenzende speel- en conversatiezaal.
„Zeker, neem plaats, kerel!” sprak Frits van Egelen. „Hoe ben je zoo vroeg
op ’t pad? Ook eruit gelokt door het reuzennieuwtje van den
schilderijendiefstal?”
„Een brutaal stukje, weergaloos brutaal!” riep een oudachtig heertje uit, dat
naast van Egelen zat. „Ik veronderstel, dat deze diefstal verband houdt
met andere Museumdiefstallen die in de laatste jaren zijn gepleegd.”
„Ons land is er in dat opzicht tot dusverre nog vrij goed afgekomen”,
beweerde de beweeglijke bankdirecteur [23]weer. „Maar ik ben het met u
eens, professor, dat het vermoeden voor de hand ligt om aan een complot
te denken.”
„Wel, men zal hier te doen hebben met een internationale bende van
museumdieven, die nu eens hun slag slaan in Italië, dan in Frankrijk of
Engeland en eindelijk ook ons landje een bezoek waardig hebben
gekeurd.”
„Maar hier, in het Rijksmuseum krioelt het immers van suppoosten!” riep
Heemberg uit. „Mij lijkt het een verduivelde kunst om dáár iets te gappen!”
„En toch ziet u, dat het mogelijk is geweest”, lachte graaf Van Sloten een
beetje ironisch.
„Ik betwijfel het, of wel ooit uit zal komen, in welke handen de
„Avondschool” is beland!” sprak de lange, magere heer naast den
professor en die aan Raffles was voorgesteld als een bekend
letterkundige.
„Zeker!” riep Heemberg uit, „ik heb vroeger eens gelezen van een
Amerikaansch millionnair die er in de onderaardsche gewelven van zijn
woning een groote verzameling op nahield van voorwerpen, die hij op
dergelijke wijze had verkregen.
„Een half menschenleven had hij eraan besteed om van her- en derwaarts
de kostbaarheden bijeen te zamelen en het eenige genot, dat bij ervan
had, was, dat hij urenlang in het diepste geheim kon ronddwalen door de
rij onderaardsche vertrekken, die als ’t ware een klein museum vormden.
„En op welke wijze is zijn geheim dan ten slotte wereldkundig geworden?”
vroeg de magere letterkundige.
„Het ware te wenschen, dat ook in dit geval, waar het den diefstal betreft
van een zoo kostbaar eigendom der Nederlandsche regeering, van zulk
een wereldberoemd meesterstuk, dat ook nu een bijzonder schrandere
detective de schuilplaats van het gestolen schilderij ontdekte!”
„Ja, hadden wij hier maar een Sherlock Holmes!” riep de kleine
bankdirecteur op levendigen toon uit.
„Wie weet!” sprak graaf Van Sloten, terwijl hij Frits van Egelen met een
hoffelijk gebaar zijn gouden sigarettenkoker voorhield.
En toen deze een sigaret uit het étui had genomen, stond graaf Van Sloten
op.
„Het wordt mijn tijd, heeren, ik heb wat hoofdpijn!” sprak hij en groette
beleefd.
Toen wendde hij zich nogmaals tot Frits van Egelen, die eveneens was
opgestaan, en vroeg met een beminnelijken glimlach:
Een oogenblik later verlieten de beide heeren samen het gebouw van de
club.
Dien middag gebruikte Jan Heemberg den lunch met [24]een paar vrienden
in Trianon, het moderestaurant op het Leidscheplein.
De zware huisdeur viel dicht achter den millionnair en nadat hij hoed en
pels aan een der bedienden had afgegeven, liep hij de breede
witmarmeren gang door en opende de deur van zijn studeerkamer.
Gestudeerd had Heemberg in deze kamer echter niet veel. Wel stonden
breede boekenkasten, gevuld met kostbare werken, langs de wanden, wel
strekte de gemakkelijke stoel voor het prachtige schrijfbureau zijn armen
uit, als om tot studie uit te noodigen daar in dat rustige vertrek, maar de
arbeid, die Heemberg hier verrichtte, bestond bijna uitsluitend in het
doorbladeren van geïllustreerde tijdschriften, het lezen en beantwoorden
van menig billet-doux.
Ook nu lagen eenige brieven, die in den loop van den dag waren
aangekomen, op de schrijftafel. Achteloos bekeek Heemberg de adressen
en legde met een onverschillig gebaar een sterk geparfumeerd briefje in
rosen omslag terzijde.
„Daar heb ik geen haast mee,” mompelde hij, „Lora verveelt mij met haar
eeuwige verwijten. Ik heb haar meer dan eens duidelijk te verstaan
gegeven, dat ik genoeg van haar heb en daar dient ze eindelijk in te
berusten. Ze is jong en mooi en zal waarachtig wel een anderen aanbidder
kunnen krijgen.”
Toen nam hij een met zilver gemonteerde papiersnijder op en opende het
eenvoudige vierkante couvert, waarop met flinke, duidelijke letters zijn
naam en adres geschreven stond.
„Kranige hand!” sprak hij tot zichzelf, terwijl hij den brief uit het enveloppe
haalde.
Zooals dat steeds zijn gewoonte was, zocht hij eerst naar de
onderteekening van den brief, maar hij zag dat deze ontbrak.
Nu begon hij den inhoud van het schrijven te lezen en steeds spannender
werd de uitdrukking van zijn gelaat, steeds grooter zijn verbazing, toen hij
het volgende las:
„Het is mij bekend, dat het sinds lang een hartewensch van u is geweest, om uw
schilderijen verzameling te kunnen aanvullen met een der kostbare werken van
onze oude meesters.
Immers, wie zou het bezit van de „Avondschool” van onzen onsterfelijken Gerard
Dou meer op prijs kunnen stellen dan gij, die de kunst zoozeer naar waarde weet
te schatten?
Ik hoop, dat het schilderij de plaats, welke het in uw collectie heeft gekregen, nog
lang zal mogen innemen.”
Tot driemaal toe herlas Jan Heemberg den inhoud van het korte briefje.
Toen stak hij het met een zenuwachtig lachje in den zak van zijn jas en
verliet het vertrek om zich haastig naar boven te spoeden.
Nauwelijks gunde hij zich den tijd om het electrische licht in de kamers,
waar zijn schilderijenverzameling zich bevond, op te draaien en toen het
heldere schijnsel der lampen de reeks vertrekken als in zonlicht baadde,
vloog zijn blik langs de hooge, breede wanden, waaraan tallooze doeken
in zwaar vergulde lijsten hingen.
Reeds was hij twee der ruime zalen, die één groot geheel vormden,
doorgeloopen, zonder dat iets buitengewoons zijn oog trok en nu trad hij
het vertrek binnen, waar eerst kort geleden het „Weesmeisje” dat hij voor
acht mille had gekocht, aan een der muren was neergehangen naast een
doek van Breitner.
Plotseling bleef Heemberg als door den bliksem getroffen staan. Hij had
zich omgewend naar den wand, waar het nieuw aangekochte stuk een
plaatsje had gekregen en met uitpuilende oogen staarde hij nu naar een
veel kleiner schilderij in zwarte omlijsting, dat precies onder het
„Weesmeisje” was opgehangen.
Het was hem alsof zijn hart ophield te kloppen, hij snakte naar adem en
zijn knieën knikten.
Dáár, vlak vóór hem, te midden van zijn eigen schilderijen, onberispelijk
aan den muur bevestigd, hing het wereldberoemde werk van Gerard Dou,
de uit het Rijksmuseum gestolen „Avondschool”!
Een oogenblik bleef hij onbeweeglijk staan, toen kneep hij zichzelf in den
arm, als om zich ervan te overtuigen, dat het geen benauwde droom was.
Maar neen, het was geen hallucinatie, het was ruwe werkelijkheid: het
gestolen doek, het waardevolle eigendom van den Staat was op
onverklaarbare wijze in zijn huis, in zijn schilderijenverzameling terecht
gekomen.
Een oogenblik dacht hij, dat hij krankzinnig was geworden. Hij viel in een
der zetels, die hier en daar waren aangebracht, neer en trachtte zijn
gedachten te verzamelen. [25]
Hoe ter wereld was dat schilderij hier gekomen? Wie had den brutalen
moed gehad, het uit het goed bewaakte Museum te stelen om het daarna
op onverklaarbare wijze hierheen te brengen?
En wie was de geheimzinnige schrijver van den brief dien hij zooeven had
ontvangen?
Als versuft bleef Heemberg een poosje voor zich uit zitten staren, toen
stond hij op, sloot alle deuren, die toegang gaven tot de reeks van
vertrekken, waarin zijn schilderijencollectie zich bevond, zorgvuldig af en
begaf zich terug naar de plek, waar de „Avondschool” hing.
Deze was op eenvoudige wijze aan den muur bevestigd, zoodat het
Heemberg niet de minste moeite kostte, het schilderij af te nemen.
Nogmaals bekeek hij met aandachtige blikken het kostbare stuk. Toen
haalde hij uit een kast in den muur een zwarten doek te voorschijn, die
weleens had gediend om een schilderij in te wikkelen, hulde de
„Avondschool” daarin en begaf zich met het noodlottige schilderij naar de
deur, die toegang gaf tot de breede, ruime gang.
Als een dief sloop hij op zijn teenen naar het rijk gebeeldhouwde
trappenhuis en, voorzichtig om zich heen kijkende, alsof hij bang was, op
heeterdaad betrapt te worden bij het plegen van een misdaad, liep hij snel
over de dikke loopers naar beneden, waar hij weer in zijn studeerkamer
verdween.
Ook hier sloot hij de kamerdeur achter zich dicht en opende toen met een
klein, kunstig bewerkt sleuteltje een zware ijzeren brandkast, die in een der
hoeken stond.
Toen hij de brandkast weer had gesloten, haalde hij eenige malen diep
adem, alsof hij voor het oogenblik van een zwaren last bevrijd was.
Hij ging bij de schrijftafel zitten, haalde nogmaals het anonieme briefje te
voorschijn en scheurde dit in duizend stukken.
„Ik mag mij wel haasten om bij Betty te komen,” mompelde hij. „Zij rekent
erop, dat ik vroeg bij haar ben en ik moet mij eerst nog kleeden voor het
diner!”
Hij stond op, wierp nog eens een blik op de massieve brandkast en ging
toen naar zijn slaapkamer om zich te kleeden voor het diner, dat hij bij
Betty zou gaan gebruiken.
Een half uur later reed zijn auto voor om den millionnair naar zijn vriendin
te brengen.
Blonde Betty vond, dat „Bobby” dien avond erg verstrooid was. [26]
[Inhoud]
ZESDE HOOFDSTUK.
Een nachtelijke verrassing.
„Apropos,” sprak lord Lister na het diner tot zijn jongen vriend. „Je hebt
vanmiddag, als ik het me goed herinner, Charly,—want je vertelt me
zooveel, waar ik maar met een half oor naar luister,—je hebt me
vanmiddag gesproken over een onbetaalde champagnerekening en over
andere schulden, die wij hier in Amsterdam hebben loopen.”
Charly knikte.
„Het doet me plezier, Edward, dat jijzelf op die kwestie terugkomt. Ik ben
eigenlijk een beetje huiverig geworden om jou nog over geldelijke
aangelegenheden te spreken. We zitten inderdaad stevig in de beren. Of
heb je misschien …?”
Met oogen vol spanning keek de jonge secretaris zijn heer en meester aan
en het zou hem zeker niet zoo heel sterk hebben verbaasd, als in dit
oogenblik de Groote Onbekende hem een reusachtig groot kapitaal had
ter hand gesteld.
Charly was gewend aan wonderen, sinds hij samenwoonde met den
gentleman-dief en als zoo’n wonder niet gebeurde op het oogenblik, dat de
jonge Brand daarvoor het meest geschikt achtte, voelde Charly zich
lichtelijk teleurgesteld en eigenlijk zelfs een beetje miskend.
Charly’s hand bleef leeg, en de eenige beweging, die lord Lister zich
veroorloofde te maken, was, dat hij een nieuwe sigaret uit den gouden
koker nam, die opstak en fijne rookwolkjes naar boven liet kringelen.
Toen bekeek hij met de grootste aandacht, een betere zaak waardig, de
asch die zich vormde voor de roodgloeiende tabak en zei:
„Ik heb je vanmiddag gezegd, my boy, dat je overmorgen je rekeningen
kunt betalen. Je weet, dat ik niet van overdrijven houd en gewend ben, bij
alles den juisten tijd te noemen.
„Je kunt dus vast op me rekenen, Charly. Maar om aan mijn verplichtingen
tegenover jou te kunnen voldoen, zul je vanavond na elf uur mijn
gezelschap moeten missen. Tot zoo lang kunnen we samenzijn en ik laat
jou de keuze om te beslissen, waar we den avond zullen passeeren.”
„Laat mij met je meegaan, Edward! Toe, laat mij je vergezellen! Ik voel, dat
je de een of andere belangrijke misdaad gaat opsporen. Laat mij je
vergezellen, op je nachtelijke expeditie! Je weet, dat ik voor geen kleintje
vervaard ben als het er op aankomt.”
Raffles lachte.
„Ik wil je alleen zeggen, en dat is dan ook het eenige, wat ik over deze
nachtelijke expeditie wil loslaten, dat hier van een misdaad geen sprake is.
„Je weet, Charly, dat ik zoo af en toe het van mijn plicht acht om den een
of anderen eervergeten losbol een gevoelig lesje toe te dienen en om zijn
beurs te openen voor een goed doel, waartoe de man anders van al zijn
millioenen geen rooje duit zou willen bijdragen.
„Ik doe dat meestal op vrij origineele manier en ook dezen keer laat de
oorspronkelijkheid van mijn truc niets te wenschen over.