Technique
The surgical technique is illustrated in the Video (Video 1, supplementary material). A transverse aortotomy is performed 1.5cm above the origin of the right coronary artery, after the heart is arrested with normothermic blood cardioplegia. The valve is assessed and confirmed to be unicuspid with a true posterior commissure at the left/non-coronary commissural position, and two raphae at the non/right-, and right/left-position (Figure1C,D) . The height of both raphae is below the height of the true posterior commissure. An additional unusual finding is a diastasis of the posterior commissure, which had to be addressed separately (Figure2C). Although the aortic root is only moderately enlarged at 4.2cm, we performed our modified reimplantation technique, since it provides the best stabilization of the functional aortic annulus, with an excellent aortic annuloplasty and support of the Sino-tubular junction7.
The aortic root is prepared and annular sutures are placed at the level of the virtual basal ring as previously described by our group7. A commissurotomy is then performed at the non/right-raphe to create a second functional commissure, and the free margins are thinned with a blade (Figure2A,B) . The remaining raphe is then shaven and thinned towards the hinge point of the anterior cusp, to allow for better mobility (Figure2C) . Attention has to be paid towards not accidentally perforating the cusp at its’ insertion.
The commissural diastasis of the posterior commissure is then addressed. The commissure is incised towards its’ tip, in order to readjust the width and to exclude some abnormal tissues in-between the cusps. The commissure is then remodeled with a 4.0 Prolene suture(Figure2D) . This resolved the commissural diastasis and excluded the abnormal tissues in-between the cusps and led to improved apposition of cusp free margins.
A 30mm Valsalva-graft is then seated onto the aortic annulus and tied down. The commissure and modified raphe are resuspended at 180º. The nadir of the fused cusp, at the raphe, is lowered to match the nadir of the non-fused cusp (Video1) . The graft is then sewn to the proximal aortic root remnant and the aortic valve is re-assessed thereafter. The anterior cusp is prolapsed and the neo-commissure is lower than the posterior commissure. We usually perform central cusp plications to treat a prolapse, but due to the good quality of cusp tissues in proximity to the neo-commissure, and the bulk of tissues centrally, we opted to perform a lateral cusp plication instead. This lateral plication at the neo-commissure can also help to somewhat elevate the commissure, if at the same time a small bite of the aortic wall is taken laterally(Figure3A,B). In addition to this, the neo-commissure was further resuspended, 5-10mm higher to match the height of the posterior commissure, utilizing a 5.0 Prolene suture with emphasis on the anterior prolapsing cusp (Figure3C,D). This is feasible, due the good quality and large amount of cusp tissues, as well as the annuloplasty, which increases cusp mobility due to a relative increase of free margin length.
There was good coaptation, with an adequate effective- and geometric height thereafter. Both coronary buttons were then reimplanted in the usual fashion, and the distal aortic anastomosis was performed, resecting the diseased aorta and wrapping the very distal ascending aorta with a piece of prosthetic graft.