Aortic valve repair in bicuspid aortic valve (BAV) with aortic regurgitation has become an attractive alternative to prosthetic replacement, particularly in young patients. However, not all anatomies are equivalent and, consequently, neither are the hemodynamic results nor durability. The option of “bicuspidizing” tricuspid aortic valves has been described, albeit with limited adoption, largely because the most reproducible (and technically accessible) root reimplantation repair is performed in Sievers 0 (no raphe) or symmetric Sievers I (type A, 160-180°) BAV. The scenario becomes more complex in asymmetric Sievers I forms (type B, 159-140°), and in very asymmetric type C forms (120-139°) some groups even recommend replacement with a valved conduit.

In the work by Okita et al., the authors present their experience with tricuspidization of BAV as an alternative strategy in carefully selected patients, effectively as a rescue approach for this particularly unfavorable BAV configuration for repair.

This article, published in the New Technology section of The Annals of Thoracic Surgery, reports a retrospective series of six patients undergoing valve-sparing root reimplantation combined with tricuspidization of a BAV with severe aortic regurgitation. These were young patients (mean age 32 years) with Sievers I C valves: three Valsalva sinuses with partial fusion and marked cusp asymmetry.

The report is predominantly technical and descriptive. The authors meticulously detail the creation of a “new commissure” by dividing the raphe of the common cusp and systematically resuspending it at 120° relative to the adjacent true commissures. Conceptually, the technique aims to restore a more physiological tricuspid geometry that facilitates effective coaptation, rather than maintaining a bicuspid configuration during root reimplantation.

A critical nuance must be emphasized here. The distinction between true commissures and the so-called “new commissure” is not trivial. The raphe, despite resembling a commissure, never reaches—by definition—the level of the coronary ostia. True commissures, conversely, are physiologically located at that level and, in David V procedures, are often reimplanted even higher to achieve adequate free-edge tension and coaptation height. Therefore, while true commissures follow this principle, the newly created commissure from the raphe cannot be reimplanted at the same height. It must be positioned lower, at 120° along the graft circumference, to allow proper coaptation between the two hemi-leaflets and the adjacent cusp.

Early results are highly favorable: no mortality, low gradients (mean 6.9 mmHg), and mild or less residual regurgitation in all patients at discharge. Although follow-up is short (mean 16 months), repair stability appears acceptable, with only one case of moderate regurgitation and no reinterventions. These findings suggest excellent valve hemodynamics, particularly when compared with some series of bicuspid repair in asymmetric anatomies, where postoperative gradients may be substantially higher.

Nevertheless, the study limitations are evident and appropriately acknowledged by the authors. This is an extremely small series derived from a single surgeon’s experience, with limited follow-up and no comparator group. Furthermore, the technique is applied to a very specific BAV subset with strict anatomical requirements: sufficient cusp geometric height, minimal calcification, incomplete raphe, and well-developed Valsalva sinuses. The message is therefore not generalizable to most Sievers I C insufficient BAVs.

Another important consideration is technical complexity. Tricuspidization combined with valve-sparing root reimplantation is a demanding procedure that adds further complexity to an already technically challenging operation. Although extensive pericardial patch augmentation is avoided, the creation of a new commissure raises unresolved questions regarding long-term durability.

The authors conclude that tricuspidization of BAV with aortic regurgitation provides acceptable early results in carefully selected patients with favorable anatomy. The technique may offer hemodynamic advantages over conventional bicuspid repair in very asymmetric valves, although longer follow-up and larger series are needed.

COMMENTARY:

This work aligns with an increasingly clear trend in aortic valve surgery: moving away from “one-size-fits-all” solutions and tailoring the repair strategy to the specific anatomy of each patient. The proposal by Okita et al. is not intended to replace classic bicuspid repair when feasible, but to provide an alternative when such an approach results in high gradients or suboptimal coaptation.

The principal value of this article is conceptual. It challenges the surgeon to reconsider whether insisting on preserving a bicuspid configuration in markedly asymmetric BAV is truly the most physiological or practical approach. Restoring tricuspid geometry may be hemodynamically advantageous, albeit at the cost of greater technical complexity.

However, caution is warranted to avoid premature enthusiasm. The history of cardiac surgery is replete with innovative techniques that demonstrated brilliant short-term outcomes yet failed the test of time. Only studies with larger cohorts, longer follow-up, and direct comparison with bicuspid repair will clarify the true role of tricuspidization. For now, this appears to be a valuable tool in expert hands rather than a broadly applicable technique.

REFERENCE:

Okita Y, Numata S, Suda H, et al. Tricuspidization of the bicuspid aortic valve with aortic regurgitation. Ann Thorac Surg. 2026;121:250-254.