Abstract
BACKGROUND: Repair of the regurgitant bicuspid aortic valve is an attractive alternative to valve replacement. Although good long-term outcomes have been reported, postoperative aortic stenosis remains a major late cause of repair failure in bicuspid aortic valves. Sinus plication is effective for creating a more symmetrical commissural angle, leading to a decrease in the mean transvalvular pressure gradient. Herein, we report a successful case of aortic valve repair with sinus plication for a regurgitant bicuspid aortic valve. CASE PRESENTATION: The patient was a 34-year-old man with bicuspid aortic valve, severe aortic regurgitation, and left ventricular dilatation. Echocardiography revealed an eccentric aortic regurgitation jet caused by a fused cusp prolapse. The commissural angle was approximately 136°, classified as asymmetrical. The patient underwent surgery via median sternotomy. Cardiopulmonary bypass was initiated using the ascending aortic and single two-stage atrial cannulation with left ventricular venting via the right superior pulmonary vein. After the ascending aorta was cross-clamped, transection was performed 5-10 mm above the sinotubular junction. Based on the valve configuration, annuloplasty, sinus plication, and ascending aortic replacement were planned in addition to triangular resection of the bulking raphe tissue with central cusp plication. Mattress sutures of 4-0 polypropylene, reinforced with autologous pericardium, were placed outside the fused cusp for sinus plication. The sutures extended from the basal ring to the sinotubular junction, reducing the sinus circumference by approximately 15 mm. Intraoperative transesophageal echocardiography revealed trivial aortic regurgitation and modified commissural angulation. The operation, cardiopulmonary bypass, and aortic cross-clamping times were 311, 129, and 95 min, respectively. The clinical course was uneventful, without major complications. Postoperative echocardiography demonstrated an improved commissural angle. Follow-up echocardiography demonstrated trivial aortic regurgitation and a decreased mean transvalvular pressure gradient. CONCLUSIONS: Sinus plication may be one of the most effective repair techniques for asymmetrical bicuspid aortic valves, especially in cases without Valsalva sinus dilation. This technique helps avoid postoperative aortic valve stenosis.