Discussion
In most cases, the TV incompetence is mild and requires no surgical therapy at the time of TAC correction. If the TV incompetence is moderate or severe, correction is necessary. A TV replacement with a mechanical prosthesis or a homograft, although technically feasible because of the usually large valvular ring, is associated with a higher morbidity and mortality due to requirement of lifelong anticoagulation and/or reoperations.
An alternative to replacement is TV reconstruction; this option is more challenging and not performed as often. Naimo et al. reported 14 patients who underwent TV surgery with different techniques at the time of TAC repair. However, the surgical techniques in this study are mentioned but not explained in detail8. We describe a detailed surgical technique which is reproducible in patients with a quadricuspid TV. In these cases, usually one of the sinuses is hypoplastic; we recommend the resection of the smallest sinus without coronary ostium. With this approach a larger coaptation area of the remaining sinuses can be achieved. To avoid postoperative obstruction of the TV it is important to ensure that after resection the TV ring should not be smaller than -1 Z Score. The limitation of this study is, that it has been performed in a single patient and therefore requires confirmation in a larger cohort of patients.