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\begin{document}

\title{A successful double valve repair on an interesting background. Case
report}



\author[1]{Dina  Alwaheidi}%
\author[1]{Tamer M. M. Abdalghafoor}%
\author[1]{Hatim Sarhan}%
\author[1]{Ali Kindawi}%
\affil[1]{Hamad Medical Corporation}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
\emph{Background---} aortic regurgitation in a bicuspid aortic valve is
a complex entity that involves not only the semilunar valve but also the
structure of the aortic root which is functionally \& pathologically in
a very close relationship to it. Considering repairing a bicuspid valve
mandates a mindful involvement of all related structures concurrently.
Here We report an interested case of both bicuspid aortic valve and
mitral valve regurgitation in a patient with history of infective
endocarditis, that was successfully managed by double valves repair.%
\end{abstract}%



\sloppy


\textbf{A successful double valve repair on an interesting background.
Case report}

\textbf{Dina Fa alwaheidi MD, Department of Cardiothoracic Surgery,
heart hospital, HMC, Doha, Qatar.}

\textbf{Tamer M. M. Abdalghafoor MD, Department of Cardiothoracic
Surgery, heart hospital, HMC, Doha, Qatar.}

\textbf{Hatem serhan MD, Department of Cardiothoracic Surgery, heart
hospital, HMC, Doha, Qatar.}

\textbf{Ali Kindawi MD, Department of Cardiothoracic Surgery, heart
hospital, HMC, Doha, Qatar.}

Background--- aortic regurgitation in a bicuspid aortic valve is a
complex entity that involves not only the semilunar valve but also the
structure of the aortic root which is functionally \& pathologically in
a very close relationship to it. Considering repairing a bicuspid valve
mandates a mindful involvement of all related structures concurrently.

Here We report an interested case of both bicuspid aortic valve and
mitral valve regurgitation in a patient with history of infective
endocarditis, that was successfully managed by double valves repair.

\textbf{Case Report}

A 33-year-old Bangladeshi male referred to our hospital with a diagnosis
of progressive mitral regurgitation. Manifestations of his disease
include mild dyspnea with exercise. Laboratory findings were normal.

His first presentation was 4 years ago when he was admitted with fever,
atypical chest pain and vomiting. Physical examination at that time
revealed a blowing systolic murmur at the apex radiating to the left
axilla. Transthoracic (TTE) and transesophageal echocardiography (TEE)
confirmed a Bicuspid aortic valve with moderate AR, a moderate MR and a
15 mm vegetation attached to the mitral valve leaflets. Blood cultures
were positive for Streptococcus sanguinis, and the patient was managed
conservatively with antibiotics; his symptoms improved, and IE was
successfully treated conservatively.

Outpatient Echocardiographic follow-up subsequently showed same degree
of moderate mitral and aortic regurgitation but a marked increase in the
left ventricular diameters along preserved function. He lost follow up
for 2 years as he sustained COVID infection. He came back with worsening
shortness of breath and palpitation. Echocardiography showed severe
mitral regurgitation with two eccentric jets, the aortic valve as well.
So patient was scheduled for double valve surgery. CT aorta was done as
pre-operative routine for bicuspid aortic valve.

Intraoperative; Aortic valve was bicuspid with fused left and right
coronary cusps, Aortic root was slightly dilated with a redundant fused
aortic leaflet contributing to the regurgitation, but sinuses were not
dilated, and coronary ostium were anatomically normal. Additionally, a
single perforation was found in A3 segment of the mitral valve leaflet.
Aortic valve repair was performed with plication of the central and the
free edge of the fused right and left aortic cusp.

A synthetic pericardial patch was used to repair the perforation in A3
section of the anterior mitral valve leaflet, followed by implantation
of a 30mm Sorin Memo 4D annuloplasty ring. Intra-operative TEE confirmed
competent repair with trivial regurgitation in both valves and no
stenosis.

Patient recovery was unremarkable, he was discharged on the fifth
postoperative day.

He was seen in the outpatient clinic after 1 year from discharge, he was
doing very well with no complains. Post-operative echocardiographic
follow up revealed same finding of trivial Mitral and Aortic valve
regurgitations.

\textbf{Discussion}

Giving the fact that Bicuspid aortic valve (BAV) anomaly is the most
common congenital cardiovascular malformation seen in the adult, which
can be a stenosed or regurgitant due to the abnormal \& unique
configuration of this valve anomaly. The reported mean age of developing
stenosis is 60 \textsuperscript{(1)}. On the other-hand regurgitation
associated with bicuspid valve is usually seen in a younger age group; a
mean age of 30 \textsuperscript{(1,2)}. Aortic dilatation is a
superimposed pathology which is seen in about 50\% to 60\% of the
bicuspid valves \textsuperscript{(3)}. Reconstruction of the regurgitant
BAV was proposed as early as 1992\textsuperscript{(4)}. Many studies
have shown the safety of BAV repair, and its durability with accepted
low mortality rates, less reoperation, and a good long-term
survival\textsuperscript{(5,6)}. Cusps prolapse due to technical errors
in a less optimal repair is one of the common causes of reoperation in
these patients; however, natural progression of the disease causing an
increase in the valve gradient post repair have been found as a culprit
that accounts for a substantial proportion of failure post repair as
well \textsuperscript{(6)}.

Repair techniques include cusp free margin plication, sub commissural
annuloplasty, free margin reinforcement.

Referring to our patient; intraoperatively aortic valve anatomy looked
suitable for valve repair, so we performed plication of both the central
and the free edge of the fused right and left aortic cusps. Aortic
dimensions were within normal range which was not indicated for any
further intervention.

Interestingly, the patient had concomitant mitral regurgitation due to
perforation of the A3 segment of the anterior mitral valve. Presumably,
due to the infective endocarditis he sustained. The mitral valve was
repaired using a synthetic pericardial patch, followed by implantation
of a 30mm Sorin Memo 4D annuloplasty ring. Nonetheless, mitral repair is
now considered a standard approach to the mitral valve since the growing
evidence of its effectiveness and durability.

Follow up Echocardiography showed competent repair in both valves.

\textbf{Conclusion}

BAV repair has become a seemingly better alternative to AVR with
favorable hemodynamics and survival, considering the younger age of
presentation of such pathology. The reported incidence of repair-related
complications is low with meticulous technique. Careful patient
selection and adequate repair gives a good durability result. Evidence
of bicuspid aortic valve preservation especially when regurgitation
dominate the pathology started to be the rule with replacement of such
valve becoming an exception.

\subsection*{Abbreviations}

{\label{abbreviations}}

\textbf{LV:} left ventricle

\textbf{BAV} : Bicuspid aortic valve

\textbf{MR:} mitral regurgitation

\textbf{MVP:} mitral valve plasty

\textbf{MVR:} mitral valve replacement

\textbf{TEE:} transesophageal echocardiography

\textbf{TTE:} transthoracic echocardiography.

\textbf{References}

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\tightlist
\item
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\item
  Nistri S, Sorbo MD, Basso C, Thiene G. Bicuspid aortic valve: abnormal
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\item
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\item
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