A 75-year-old woman presenting with dyspnea and chest pain underwent cardiac catheterization revealing three-vessel coronary artery disease with severe calcific aortic stenosis and dilated aortic root (Figure 1). A multi-gated acquisition scan (MUGA) was performed revealing LVEF to be 50%, reassuring consensus to proceed with aortic valve replacement and concomitant coronary artery bypass grafting. She was brought to the cardiovascular operating room (CVOR) in stable condition. Routine cardioplegia ensued after placement on cardiopulmonary bypass and grafting was performed to the obtuse marginal, posterior descending, and left anterior descending arteries. Upon successful grafting, attention shifted to the aorta. A transverse incision was made 2cm above the annulus, exposing the valve. A severely thickened, unicuspid, unicommisural aortic valve was observed (Figure 2) and replaced with a 23mm Edwards ® Inspiris TM valve. Unicuspid unicommisural aortic valves are rare manifestations with a prevalence of 0.02% 1. They precipitate congenital aortic stenosis in patients within the first 4th-6th decades of life 2. Outcomes are promising with aortic valve replacement 3. Herein, we showcase this anomaly manifesting symptomatically in a septuagenarian, with successful surgical replacement and coronary bypass grafting.

The implementation of automatic fasteners such as the Cor-knot ® device (LSI Solutions, Inc.) has revolutionized the field of minimally invasive valvular surgery. Nonetheless, paravalvular regurgitation, valvular embolization, and early leaflet perforation are all potential complications which may occur. Late manifestations of leaflet perforation (>5-year post-implantation) are rare. Herein, we discuss a patient who underwent remote Trifecta ® (St. Jude, Inc.) surgical aortic valve replacement (SAVR) presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot ® sutures.