Comments
Unicuspid AVs are rare congenital malformations. However, the true
prevalence of this valve morphology is likely underreported. For
instance, Noly et al. reported that only 14% of patients with UAV were
diagnosed preoperatively 8. Even intraoperatively, UAV
may remain under-recognized due to severe calcifications for instance;
or inexperience of the surgeon or echocardiographer with identification
of complex AV-morphologies.
Unicuspid AVs, without severe calcifications, can be repaired through
bicuspidization. The standard technique is a butterfly patch repair4, with symmetrization of the cusps and improvement of
cusp mobility, through additional modifications of the functional aortic
annulus (e.g. annuloplasty, sinus plication), and thinning of the raphe.
In selected patients, Matsushima et al. have achieved a UAV-repair
without patch material, through cusp nadir relocation and root
remodeling. This achieved a relative elevation of the newly created
commissure, which then more closely matched the height of the true
commissure 6. The reason for this approach is to
obviate the accelerated degeneration of autologous or xenogenic
pericardial patch material, which renders this a palliative repair
approach, and thus only allows for deferment of valve replacement later
in life. Nonetheless, this is still an advantage in children and
adolescents, and we think it is also of benefit when employed in adults,
as the better survival of valve repair compared to prosthetic valve
replacement is now well documented. Moreover, this may also function as
a bridge to a Ross-procedure later in life, in children but also in
younger to middle-aged adults.
In this patient however, we performed an AV-repair without a patch,
through commissurotomy of a raphe to create a second commissure and two
symmetric cusps. We further enhanced symmetry through reimplantation of
the commissures at 180ยบ. Cusp mobility was improved through
annuloplasty, as well as thinning of the free margins and raphe, and
repair of a commissural diastasis. The anterior commissure was elevated
through cusp plication and additional resuspension. Since no additional
patch material was used, we hope that we were able to minimize the risk
of cusp degeneration with overall improvement in valve longevity,
similar to our bicuspid AV-repairs 9.