Commentary: Skinning a cat starts with anatomy.

Kevin Beers, DO, and John Calhoon, MD

The authors describe a durable appearing novel method of quadricuspid aortic valve repair. The associated video clip clearly illustrates the method.

See Article page 28.

Perrier and colleagues describe a novel method of repairing a quadricuspid aortic valve. The attraction of valve repair avoids placement of a prosthesis and future valve-related complications (eg, degeneration, potential for reoperation, and anticoagulation). This technique is similar to published methods of repairing truncal valves with more than 3 cusps.

For valve repair to be efficacious and durable, the anatomy has to be right. This starts with the quality of the leaflets to be preserved and absence of calcification, perforations, or infectious/inflammatory processes. The patient described had favorable anatomy in that only 1 of the 4 cusps was poorly aligned, resulting in significant insufficiency. In addition, the accessory cusp that prolapsed had no associated coronary artery arising from its sinus. Other concerns for the aorta include making sure the sinus being removed or obliterated does not involve the atrial valve nodal area and removal or obliteration will not affect the mitral valve. Thus, favorable anatomy allowed for the approach taken by the authors.

They are to be congratulated on such clear illustration and the complementary video documenting a nice procedure and result. I am sure the authors would agree with me that caution should be taken when key anatomic construct is missing. Obviously, one cannot obliterate a sinus containing a coronary nor can one so easily fix such a valve with multiple prolapsing cusps. Damaging conduction also would be unfavorable. Enough about worry; the nice features of such a repair are durability of the tissue, connection, and use of what amounts to native fibrous tissue serving as pledget material. This is supported by pathologic evaluation describing a normal-appearing aortic wall.

In our limited experience, such a valve repair is facilitated or even enhanced when one almost imperceptibly narrows the subcommissural triangle during resection and exclusion of the prolapsing leaflet and sinus. This creates a geometry allowing for a longer zone of coaptation, resulting in a more competent valve. Finally, an obvious point is ensuring the aortic reconstruction is hemostatic because extra sutures needed once off cardiopulmonary bypass might distort or damage an otherwise good result.

Congratulations on a nice report illustrating how to take a leak away.