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Commentary: What can be learned from a case report, or the importance of a well-rounded education

  • Petros V. Anagnostopoulos
    Correspondence
    Address for reprints: Petros V. Anagnostopoulos, MD, American Family Children's Hospital, H4/358, Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792.
    Affiliations
    Division of Pediatric Cardiothoracic Surgery, Department of Surgery, The American Family Children's Hospital, The University of Wisconsin Hospital and Clinics, Madison, Wis
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Open ArchivePublished:July 25, 2019DOI:https://doi.org/10.1016/j.jtcvs.2019.07.023
      A well-rounded training program that exposes trainees to a breadth of experience may come in handy when coming across a lesion that requires an unusual repair.
      See Article page e341.
      Quadricuspid aortic valves (QAVs) are very rare but have been well described since the early 1970s.
      • Hurwitz L.E.
      • Roberts W.C.
      Quadricuspid semilunar valve.
      Even less recognized but documented is the association of QAVs with a potential congenital structural aortopathy. In the largest series of QAVs to date, 42% of patients had ascending aortic diameters greater than or equal to 4 cm.
      • Idrees J.J.
      • Roselli E.E.
      • Arafat A.
      • Johnston D.R.
      • Svensson L.G.
      • Sabik III, J.F.
      • et al.
      Outcomes after repair or replacement of dysfunctional quadricuspid aortic valve.
      Most patients with QAVs present with aortic insufficiency, aortic stenosis, or a combination of these. In this issue of the Journal, Xu and associates
      • Xu M.
      • Song L.
      • Xiao H.
      • Tao L.
      Surgical repair of quadricuspid aortic valve associated with ruptured sinus of Valsalva aneurysm.
      report on a 35-year-old woman who presented with a QAV associated with a ruptured sinus of Valsalva aneurysm. A tricuspidization procedure was performed, with resection of the smaller ruptured right anterior sinus of Valsalva with the associated cusp, with a great clinical outcome. Time will tell whether this will lead to a durable long-term result. Although the technique of tricuspidization is well described in QAVs, it was first applied in truncus arteriosus repair.
      • Imamura M.
      • Drummond-Webb J.J.
      • Sarris G.E.
      • Mee R.B.
      Improving early and intermediate results of truncus arteriosus repair: a new technique of truncal valve repair.
      Information regarding the long-term outcomes after these repairs in truncus arteriosus exists in the congenital literature.
      • Myers P.O.
      • Bautista-Hernandez V.
      • del Nido P.J.
      • Marx G.R.
      • Mayer J.E.
      • Pigula F.A.
      • et al.
      Surgical repair of truncal valve regurgitation.
      This interesting report underscores the importance of well-rounded surgical training and education, with exposure to complex repair techniques of different acquired and congenital heart pathologies. One simply never knows when the patient will show up who is a great candidate for an unusual repair technique that uses principles that have been described in a totally different setting. This becomes ever more important as trainees are asked to master new technologies or to focus on a niche in adult cardiac surgery to remain competitive in the marketplace. Such subspecialty focus typically occurs at the expense of hands-on time and exposure to congenital heart surgery.

      References

        • Hurwitz L.E.
        • Roberts W.C.
        Quadricuspid semilunar valve.
        Am J Cardiol. 1973; 31: 623-626
        • Idrees J.J.
        • Roselli E.E.
        • Arafat A.
        • Johnston D.R.
        • Svensson L.G.
        • Sabik III, J.F.
        • et al.
        Outcomes after repair or replacement of dysfunctional quadricuspid aortic valve.
        J Thorac Cardiovasc Surg. 2015; 150: 79-82
        • Xu M.
        • Song L.
        • Xiao H.
        • Tao L.
        Surgical repair of quadricuspid aortic valve associated with ruptured sinus of Valsalva aneurysm.
        J Thorac Cardiovasc Surg. 2020; 159: e341-e342
        • Imamura M.
        • Drummond-Webb J.J.
        • Sarris G.E.
        • Mee R.B.
        Improving early and intermediate results of truncus arteriosus repair: a new technique of truncal valve repair.
        Ann Thorac Surg. 1999; 67: 1142-1146
        • Myers P.O.
        • Bautista-Hernandez V.
        • del Nido P.J.
        • Marx G.R.
        • Mayer J.E.
        • Pigula F.A.
        • et al.
        Surgical repair of truncal valve regurgitation.
        Eur J Cardiothorac Surg. 2013; 44: 813-820

      Linked Article

      • Surgical repair of a quadricuspid aortic valve associated with a ruptured sinus of Valsalva aneurysm
        The Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 6
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          A 35-year-old woman presented with a history of gradually worsening dyspnea on exertion. Clinical examination revealed a diastolic murmur heard loudest along the upper left sternal border, which did not radiate to the carotids or the precordium. Transthoracic echocardiography demonstrated a quadricuspid aortic valve (type A, Hurwitz and Robert's classification) with an aorta-to-right atrium fistula (sinus 2) through a ruptured right-anterior sinus of Valsalva (Figure 1, A). In addition, the coronary orifices originated from sinus 1 (right coronary artery) and sinus 4 (left main coronary artery), and the aortic regurgitation was moderate (Figure 1, A and B).
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