Aortic valve reconstruction in bicuspid aortic valve
In patients with bicuspid aortic valve, the choice to reconstruct 02 cusps or 03 cusps depended on the type of bicuspid valve. In true bicuspid aortic valve (type 0) with 02 equal-sized cusps, we performed a reconstruction surgery preserving bicuspid morphology (Figure 3). In contrast, we reconstructed the bicuspid aortic valve with 03 cusps in cases of type I (one raphe and a third commissure). Ozaki et al. implemented reconstruction for all types of the bicuspid aortic valve with 03 cusps because the authors believed that the area formed by 03 cusps was more optimal than 02 cusps.18 As reported by Aicher et al., the long-term outcomes of aortic bicuspid valve reconstruction in 316 patients were excellent after ten years.19 In our view, tricuspid morphology was physiological to patients; however, in type 0 bicuspid aortic valve, the preservation of bicuspid morphology was a proper solution to avoid dividing up the aortic annulus as well as direct suturing to the aortic wall which could lead to complications such as aortic dissection and postoperative bleeding. Besides, since the cusps sizes were measured by the distance between 02 commissures, the reconstructed valve would open in a circular shape with greater effective orifice area; therefore, valve hemodynamics were comparable to that of 3-cusp reconstruction (Table 4).