Repair of Quadricuspid Aortic Valve Associated with Marfan Aortic Root Aneurysm

Please explain the educational or technical point that this video addresses.: Learn techniques for quadricuspid valve repair.

Please provide a 250 word summary of the surgical video being submitted.: Quadricuspid aortic valve (QAV) is a complex defect that has been difficult to repair. This video illustrates reconstruction of a QAV associated with an aortic root aneurysm. The patient was a 48 year-old female with Marfan syndrome, history of QAV, worsening aortic insufficiency (AI), and ascending aortic/root dilatation. Left ventricular function was deteriorating, causing Class III congestive heart failure. The echo showed four aortic valve cusps with severe central AI. Annular diameter was 2.9 cm, and sinus diameter was 4.4 cm, significant for Marfan syndrome. At surgery, a poorly developed false commissure was evident in the right coronary cusp with a shallow sub-commissural triangle. Leaflet free-edge lengths suggested a 21 mm tri-leaflet annuloplasty ring, which was sutured under the valve inflow annulus. The frenulum of the false commissure was divided, allowing the right coronary leaflet to fall into coaptation. The false commissure was closed progressively until the effective heights and lengths for all 3 leaflets were similar. The enlarged non-coronary sinus was excised, and a 28 mm tube graft was selected as 7 mm larger than the ring. A 120-degree tongue was fashioned from the graft, sutured to the sinus rim, and the proximal anastomosis completed. After repair, the leaflets coapted well, with trivial AI and a mean pressure gradient of 6 mmHg. Postoperative CT angiogram showed a normal appearing ascending aorta and root. Repair of this type of QAV is facilitated by commissural tricuspidization using tri-leaflet ring annuloplasty. Release and suturing the false commissure creates a fully competent valve.