Quadricuspid aortic valves

Clinical Variability in Presentation and Management of Quadricuspid Aortic Valve: A Case Series

•Rare presentation of three QAV cases with varied clinical manifestations is reported. •Multimodal imaging is crucial for accurate QAV diagnosis and classification. •QAV is often associated with aortic regurgitation requiring intervention. •Surgical repair is preferred over replacement in suitable patients with QAV. •Long-term follow-up is essential for patients with QAV, even if asymptomatic.

Quadricuspid Aortic Valve: A Rare Case of Endocarditis Suspicion and Management

Quadricuspid aortic valve (QAV), a rare congenital cardiac anomaly, often presents with aortic regurgitation and can lead to significant cardiovascular complications. This case report describes a 55-year-old male with a history of subarachnoid hemorrhage who was incidentally found to have QAV with possible endocarditis. Transesophageal echocardiography revealed thickened leaflet tips on all four cusps and a mass on one leaflet, raising suspicion of endocarditis despite the absence of vegetation. The patient was treated with intravenous antibiotics for Gram-positive bacteremia, and follow-up imaging confirmed the QAV anomaly with moderate aortic regurgitation. This case highlights the challenges in diagnosing QAV, particularly in asymptomatic individuals, and underscores the need for comprehensive investigation, especially in those with a history of vascular events. It also emphasizes the importance of further research to clarify the long-term risks and optimal management strategies for individuals with QAV, including the potential for infective endocarditis.

Asymptomatic, Incidental Quadricuspid Aortic Valve: A Case Report and Discussion of Management

With its exceeding rarity, there is little research on the quadricuspid aortic valve (QAV) inherently to drive guideline-based management. This leaves physicians without evidence-based guidance on the management of such patients should they come across this finding on imaging or should they care for a symptomatic patient. This article describes the case of an incidentally identified QAV in a patient undergoing treatment for tuberculosis, which seemingly had bicuspid-appearing valve hemodynamics. Additionally, current literature is reviewed to describe classification, presentation, complications, and intervention, with additional exploration and commentary on the lack of guideline-based care.

Clinical features of quadricuspid aortic valve in middle-aged and elderly patients: Insights from a regional study

BACKGROUND

Quadricuspid aortic valve (QAV) is a rare congenital disease. The clinical characteristics of this disease remain unclear except for those in relatively young patients reported from tertiary referral hospitals. The aim of this study was to determine the clinical features of QAV in a regional population.

METHODS AND RESULTS

We retrospectively investigated 25 340 consecutive patients over middle age (median age, 73 (IQR 65-80) years; range, 45-102 years) who underwent transthoracic echocardiography (TTE) at our institute during the period from April 2008 to December 2023. Eight (0.032%) of the patients (median age, 65 years; range, 47-91 years) were diagnosed with QAV. Six patients suffered from aortic regurgitation (AR), and one patient had mild aortic stenosis at the time of QAV diagnosis. Two patients who had severe AR at referral underwent aortic valve surgery. The severity of AR in the other patients was moderate or less. During a median follow-up period of 27 months (range, 1-171 months), none of the patients other than above two patients had cardiac events. One patient died from a non-cardiac cause at 94 years of age.

CONCLUSIONS

Patients diagnosed with QAV after middle age, who do not exhibit severe valve insufficiency at the time of diagnosis, may not experience worse clinical outcomes. However, further research is required for a better understanding of the long-term outcomes.

Quadricuspid Pulmonary Valve: Case Report and the Comparison with Quadricuspid Aortic Valve

BACKGROUND

Quadricuspid pulmonary valve (QPV) is a rare congenital anomaly. Simple QPV had been mainly diagnosed at the time of autopsy before 2000, and the frequency rates of QPV are approximately 0.02%-0.41%. QPV was initially diagnosed using transthoracic echocardiography (TTE) after 2000 and with contrast computed tomography (CT) or cardiac magnetic resonance imaging (CMR) after 2009. Obtaining the cross-sectional view of the pulmonary valve using TTE is difficult. We aimed to review the papers regarding the incidence, embryology, diagnosis, associated congenital heart anomalies, and prognosis in patients with QPV, and furthermore to compare with those in patients with quadricuspid aortic valve (QAV).

CASE PRESENTATION

We diagnosed QPV with mild stenosis in a 12-month-old infant. With a slight angulation of the transducer superiorly from the left high parasternal short-axis view, a short-axis view of QPV was obtained.

RESULTS

In QPV cases diagnosed at autopsy, Hurwitz's type-b with three equal cusps and one smaller cusp is dominant, whereas Hurwitz's type-a with four equal cusps is dominant in clinically diagnosed cases. Congenital heart anomaly and valvular stenosis are more frequent in patients with QPV than in patients with QAV. Coronary artery anomalies and infectious endocarditis are more frequent in patients with QAV than in patients with QPV. The incidence of PR is more common in type-a QPV than in type-b QPV. There is no difference between type-a QAV and type-b QAV with respect to the incidence of aortic regurgitation (AR). It is assumed that QPV is a risk factor for a Ross operation. However, QPVs have been used as autografts in certain patients.

CONCLUSION

Between QPV and QAV, various differences were found in frequency rates, diagnostic methods, valve morphology, valve function, associated congenital heart diseases, and frequencies of infectious endocarditis.

Quadricuspid Aortic Valve With Guarded Left Coronary Artery Ostium in an Infant With Myocardial Infarction

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Anatomical variations of the aortic valve include unicuspid, bicuspid, and quadricuspid.

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The bicuspid aortic valve is most common and affects 1%-2% of the general population.

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QAV is generally an isolated malformation, and adults most commonly present with AR.

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Coronary anomalies have been reported in up to 10% of patients with QAV.

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Prompt and accurate imaging will lead to corrective surgery.

Prevalence, multimodality imaging characterization, and mid-term prognosis of quadricuspid aortic valves: an analysis of eight cases, based on 160 004 exams performed during 12 years in a tertiary care hospital

AIMS

Quadricuspid aortic valve (QAV) is a rare abnormality, which may cause aortic regurgitation (AR) requiring surgical intervention in some patients. The characteristics associated with aortic valve functional degeneration in patients with QAV are still unknown. The aim of this study is to describe QAV prevalence, characterize the disease by multimodality imaging, evaluate predictors of severe AR, and assess mid-term prognosis.

METHODS AND RESULTS

Retrospective search in imaging exams database of one tertiary centre, for patients diagnosed with QAV between January 2007 and September 2019. QAV was characterized by cardiac computed tomography, transthoracic/transoesophageal echocardiography, and cardiac magnetic resonance. A total of 160 004 exams were reviewed and eight patients with QAV were identified (50% men, mean age 53.5 ± 10.7 years). The prevalence of QAV was 0.005%. During a median follow-up of 52 months (interquartile range 16-88), there were no deaths. Seven patients (88%) had pure AR (three severe, one moderate, and three mild) and one patient (12%) had moderate AR and moderate aortic stenosis. Three patients (38%) with severe AR underwent valve surgery (two replacements and one repair). Analysis of predictors of severe AR was not statistically significant.

CONCLUSION

QAV is a rare congenital cardiac defect, with a prevalence of 0.005% in our study. Its predominant functional abnormality was regurgitation and about one-third of the patients required aortic valve surgery. Multimodality imaging may play a pivotal role in assessing patients with QAV with significant valve dysfunction or associated congenital heart disease and improve their treatment strategy.

A Congenital Quadricuspid Aortic Valve Associated With Aortic and Mitral Regurgitation: Case Report and Literature Review

Quadricuspid aortic valve (QAV) is a rare congenital cardiac anomaly that commonly becomes symptomatic in the fifth or sixth decade of life and can present as an isolated finding or in association with other congenital cardiovascular abnormalities. Previously, QAV was mainly a postmortem or intraoperative diagnosis and data was very limited on its natural history, associated complications, and long-term outcomes. In recent decades, however, there has been an increase in the reported cases of QAV, considering the advances in the diagnostic modalities such as transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and cardiac magnetic resonance (CMR). In this article, we present a case of a congenital QAV associated with aortic regurgitation as well as briefly review the QAV classification systems, treatment options, and long-term outcomes.

A 48-year-old woman with a significant past medical history (PMH) of hypertension and coronary artery disease presented with shortness of breath, chest pain, and orthopnea for two to three weeks. The patient’s TTE showed severe aortic regurgitation with significant compromise in cardiac output that could not be otherwise explained. Subsequently, her TEE revealed QAV as the underlying source of these findings.

Although the diagnosis of QAV could be very challenging, it is crucial to be considered when evaluating a patient with inscrutable progressive aortic regurgitation. Today, as a result of technological advancement, QAV is being diagnosed more accurately and promptly. Since there are no universal guidelines defined for this cardiac anomaly, regular follow-up with these patients is imperative to monitor for early signs of valvular compromise and to treat accordingly through medical and surgical interventions.

Quadricuspid aortic valve: a case report and review of literature

Quadricuspid aortic valve, a rare congenital cardiac defect, manifests most commonly as aortic regurgitation. Clinical presentation mainly depends on the functional status of the aortic valve, myocardium and associated cardiovascular abnormalities. Aortic valve replacement or repair is usually warranted in the 5th or 6th decade.

Quadricuspid aortic valve: a case report and review of the literature

Quadricuspid aortic valve (QAV) is a rare congenital anomaly that can present as aortic insufficiency later in life. We report a case of aortic regurgitation associated with a QAV, treated by aortic valve replacement. The patient presented with breathlessness, lethargy and peripheral oedema. Echocardiography and cardiac magnetic resonance revealed abnormal aortic valve morphology and coronary angiography was normal. The presence of a quadricuspid aortic valve was confirmed intra-operatively. This was excised and replaced with a bioprosthetic valve and the patient recovered well postoperatively. Importantly, the literature indicates that specific QAV morphology and associated structural abnormalities can lead to complications. Hence, early detection and diagnosis of QAV allows effective treatment. Aortic valve surgery is the definitive treatment strategy in patients with aortic valve regurgitation secondary to QAV. However, the long-term effects and complications of treatment of this condition remain largely unknown.

Quadricuspid Aortic Valve: A Rare Cause of Aortic Regurgitation

• Quadricuspid aortic valve is a rare finding in patients with aortic valvulopathy. • Patients over age 40 with this finding are more likely to have valve dysfunction. • Transesophageal echocardiogram is preferred to evaluate quadricuspid aortic valves.

Quadricuspid Aortic Valve: A Case Report and Review

Quadricuspid aortic valve (QAV) is a rare congenital valvular abnormality with less than 200 cases reported to date. The first QAV was reported in 1862 by Balington. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated cardiac disorders. Most QAV are asymptomatic and are incidentally found. Severe aortic regurgitation and/or stenosis can develop overtime, requiring aortic valve replacement or repair. Transesophageal echocardiography is the preferred modality to diagnose QAV. We present a case of QAV which was incidentally diagnosed in a 43-year-old woman who presented with gastroenteritis.

Pathology of the Aortic Valve: Aortic Valve Stenosis/Aortic Regurgitation

PURPOSE OF REVIEW

This discussion is intended to review the anatomy and pathology of the aortic valve and aortic root region, and to provide a basis for the understanding of and treatment of the important life-threatening diseases that affect the aortic valve.

RECENT FINDINGS

The most exciting recent finding is that less invasive methods are being developed to treat diseases of the aortic valve. There are no medical cures for aortic valve diseases. Until recently, open-heart surgery was the only effective method of treatment. Now percutaneous approaches to implant bioprosthetic valves into failed native or previously implanted bioprosthetic valves are being developed and utilized. A genetic basis for many of the diseases that affect the aortic valve is being discovered that also should lead to innovative approaches to perhaps prevent these disease. Sequencing of ribosomal RNA is assisting in identifying organisms causing endocarditis, leading to more effective antimicrobial therapy. There is exciting, expanding, therapeutic innovation in the treatment of aortic valve disease.

Valve-sparing aortic root replacement combined with bicuspidization for a quadricuspid aortic valve

Quadricuspid aortic valves are rare congenital malformations. Although aortic valve replacement is the first-choice treatment in most cases, aortic valve repair using a tricuspidization procedure has been reported. Herein, we report the case of a patient with a quadricuspid aortic valve associated with aortic insufficiency that we successfully repaired with aortic valve-sparing root replacement and bicuspidization.

New morphological classification of congenital quadricuspid aortic valve and its histopathologic features

We report a 52-year-old male patient who had a quadricuspid aortic valve (QAV) associated with aortic regurgitation (AR) and left ventricular hypertrophy (LVH). A new accessory cusp (ACC) with maximum thickness than other cusps was located between right coronary cusp (RCC) and left coronary cusp (LCC). The histopathological features revealed markedly thickened and distorted cusp architecture with fibrosis and/or myxomatous degeneration in both non-coronary cusp (NCC) and ACC. Two equal sizes for larger cusps (RCC and NCC) and two equal sizes for smaller cusps (LCC and ACC) were obtained. This QAV belonged to type C QAV of Hurwitz's classification, but also suggested as a modified type III of Jagannath's classification or a new type V of Nakamura's classification by locating ACC between RCC and LCC.

Quadricuspid aortic valve infective endocarditis

Infective endocarditis complicating a quadricuspid aortic valve (QAV) is rare. Previous reports highlight the increased risk for complications, including progressive aortic regurgitation, decompensated heart failure, and valve perforation. Thus, cardiologists must be able to quickly identify QAVs to guide rapid evaluation and treatment. We report a case of infective endocarditis in a QAV identified on echocardiography and effectively managed with medical therapy alone without complications over an 8-year follow-up period. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:145-148, 2018.

Quadricuspid aortic valve: A rare intraoperative diagnosis by transesophageal echocardiography

Quadricuspid aortic valve (QAV) is a rare congenital anomaly frequently associated with other anomalies particularly coronary anomalies. It may be detected on transthoracic or transesophageal echocardiography. We present here a case report of a 27-year-old male patient with a QAV, the valve being regurgitant and requiring aortic valve replacement. It has been reported as isolated case reports in the literature and various theories exist to the development of QAV. The diagnosis requires a high degree of suspicion and a detailed assessment, and if asymptomatic, then patients need to be carefully followed up for the development of aortic regurgitation.

Quadricuspid Aortic Valve: A Comprehensive Review

Quadricuspid aortic valve (QAV) is a rare congenital heart disease. The functional status of QAV is predominantly a pure aortic regurgitation. Clinical manifestations of patients with a QAV depend on the functional status of the QAV and the associated disorders. Significant valvular regurgitation and (or) stenosis is often present with subsequent operation performed at the fifth to sixth decade of life. The functional status of QAV is predominantly regurgitant; whereas pure stenotic QAV can be as few as in only 0.7% of the patients. QAV is usually an isolated anomaly, but other congenital heart defects can be present in 18-32% of the patients. About one-fifth of them require a surgical operation. Tricuspidalization is a preferred technique for QAV repair. As not all the patients with a QAV necessarily warrant a surgical operation, decision-making in patient selection and surgical procedure of choice are crucial. Antibiotic prophylaxis against infective endocarditis is necessary in the QAV patients with unequal-sized cusps.

Single coronary ostium in a patient with quadricuspid aortic valve combined with aneurysmal ascending aortic dilatation

Background

The presence of a fourth aortic valve cusp (quadricupsid aortic valve) is a rare congenital malformation and is often accompanied by other anomalies of the adjacent cardiovascular structures. Among these concomitant anomalies, simultaneous association of both a single coronary ostium and aneurysmal ascending aortic dilation in combination with the quadricupsid aortic valve has not been reported yet.

Case presentation

We experienced the case of a 56-year-old female patient presenting as aortic regurgitation resulted from malcoaptation of quadricupsid aortic valve. The patient had also accompanying aneurysmal ascending aortic dilatation and coronary ostial anomaly. Surgical correction (aortic valve replacement with mechanical devices and supracoronary aortic replacement with prosthetic graft) was performed without any complications.

Conclusions

The technological development of preoperative imaging studies enable the physician to encounter the quadricuspid aortic valve with other associated malformations more often unlike previous reports. With review on the quadricuspid aortic valve, we discussed a surgical considerations for the treatment of this anomaly.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-017-0622-4) contains supplementary material, which is available to authorized users.

Intraoperative diagnosis of a quadricuspid aortic valve

Quadricuspid aortic valve is a rare anomaly, and most patients require surgery for aortic regurgitation in the 5th or 6th decades of life; only a few cases of aortic valve repair in childhood have been reported. A 3-year-old boy was scheduled for ventricular septal defect closure and aortic valve repair. Quadricuspid aortic valve was an incidental finding at operation; it was repaired by joining the left anterior and right anterior cusps. At the 9-month follow-up, the patient had no more than mild aortic regurgitation. We emphasize the importance of detecting this anomaly, especially in children with aortic valve regurgitation.

Female Adolescent With Quadricuspid Aortic Valve

Quadricuspid aortic valve is a rare congenital heart defect. The authors present a case of this anomaly in a young, asymptomatic adolescent who presented to the echocardiography laboratory for further evaluation of a cardiac murmur detected on routine physical examination. Imaging revealed a quadricuspid aortic valve with aortic regurgitation. This case highlights the importance of auscultation in detecting cardiac abnormalities.

Morphological and Functional Evaluation of Quadricuspid Aortic Valves Using Cardiac Computed Tomography

Objective

The aim of this study was to identify the morphological and functional characteristics of quadricuspid aortic valves (QAV) on cardiac computed tomography (CCT).

Materials and Methods

We retrospectively enrolled 11 patients with QAV. All patients underwent CCT and transthoracic echocardiography (TTE), and 7 patients underwent cardiovascular magnetic resonance (CMR). The presence and classification of QAV assessed by CCT was compared with that of TTE and intraoperative findings. The regurgitant orifice area (ROA) measured by CCT was compared with severity of aortic regurgitation (AR) by TTE and the regurgitant fraction (RF) by CMR.

Results

All of the patients had AR; 9 had pure AR, 1 had combined aortic stenosis and regurgitation, and 1 had combined subaortic stenosis and regurgitation. Two patients had a subaortic fibrotic membrane and 1 of them showed a subaortic stenosis. One QAV was misdiagnosed as tricuspid aortic valve on TTE. In accordance with the Hurwitz and Robert's classification, consensus was reached on the QAV classification between the CCT and TTE findings in 7 of 10 patients. The patients were classified as type A (n = 1), type B (n = 3), type C (n = 1), type D (n = 4), and type F (n = 2) on CCT. A very high correlation existed between ROA by CCT and RF by CMR (r = 0.99) but a good correlation existed between ROA by CCT and regurgitant severity by TTE (r = 0.62).

Conclusion

Cardiac computed tomography provides comprehensive anatomical and functional information about the QAV.

Quadricuspid Aortic Valve: A Rare Congenital Cause of Aortic Insufficiency

Quadricuspid aortic valve (QAV) is a rare congenital cardiac anomaly causing aortic regurgitation usually in the fifth to sixth decade of life. Earlier, the diagnosis was mostly during postmortem or intraoperative, but now with the advent of better imaging techniques such as transthoracic echocardiography, transesophageal echocardiography (TEE), and cardiac magnetic resonance imaging, more cases are being diagnosed in asymptomatic patients. We present a case of a 39-year-old male who was found to have QAV, with the help of TEE, while undergoing evaluation for a diastolic murmur. The patient was found to have Type B QAV with moderate aortic regurgitation. We also present a brief review of classification, pathophysiology, and embryological basis of this rare congenital anomaly. The importance of diagnosing QAV lies in the fact that majority of these patients will require surgery for aortic regurgitation and close follow-up so that aortic valve replacement/repair is done before the left ventricular decompensation occurs.

Quadriscupid Aortic Valve with Concurrent Aortic Stenosis and Insufficiency

We present the case of a 22-year-old man with a congenital mixed aortic valve dysfunction who underwent cardiac Magnetic Resonance Imaging (MRI) for the assessment of aortic valve morphology and function prior to valve replacement. Cardiac MRI showed a four-leaf-clover aortic valve morphology, the typical presentation of a quadricuspid aortic valve. The patient underwent a successful Bentall procedure to replace the aortic valve, aortic root and ascending aorta. This case report illustrates the MRI findings of a quadricuspid aortic valve with associated aortic stenosis and regurgitation.

Quadricuspid Aortic Valve

Background—

Quadricuspid aortic valve (QAV) is a rare congenital cardiac defect. This study sought to determine QAV frequency in a large echocardiography database, to characterize associated cardiovascular abnormalities, and to describe long-term outcomes.

Methods and Results—

Fifty patients (mean±SD age, 43.5±21.8 years at the time of the index diagnosis; female sex, 52%) received a diagnosis of QAV between January 1, 1975, and March 14, 2014 (frequency, 0.006%). The QAV was type A in 32% and type B in 32% (Hurwitz and Roberts classification). Aortic dilatation was present in 29% of the patients, and 26% had moderate or severe aortic valve regurgitation at the index diagnosis. Stenosis affected only 8% of the valves and was mild. Other findings, including abnormalities of other cardiac valves, septal defects, persistent left superior vena cava, and patent ductus arteriosus, were present in 32% of patients. During a mean±SD follow-up of 4.8±5.6 years, 8 patients underwent aortic valve surgery, with severe aortic valve regurgitation being the surgical indication in 7 patients. One patient with mild to moderate aortic valve regurgitation underwent aortic valve repair for obstruction of the left coronary ostium by the accessory cusp of QAV. No infective endocarditis or aortic dissection was found. Overall survival was 91.5% and 87.7% at 5 and 10 years.

Conclusions—

Aortic dilatation and other structural cardiac abnormalities were relatively common among patients with QAV. Aortic valve regurgitation was the predominant hemodynamic abnormality and the indication for aortic valve surgery in most patients who received surgery. Long-term survival was excellent.

Quadricuspid aortic valve diagnosed by multidetector computed tomography (MDCT)

A quadricuspid aortic valve is very rare form of congenital cardiac valvular disease with an incidence between 0.003 and 0.043% and often incidentally found during echocardiography, surgery or on post-mortem examination (Feldman BJ, Khandheria BK, Warnes CA, Seward JB, Taylor CL, Tajik AJ. Incidence, description and functional assessment of isolated quadricuspid aortic valves. Am J Cardiol 1990; 65 : 937-8). Its diagnosis is often missed, even with the transthoracic echocardiogram, as in this patient. We report a case of a quadricuspid aortic valve that was incidentally found by 256-slice electrographically-gated multidetector row CT/tomographic angiography during screening for coronary artery disease.

Quadricuspid Aortic Valve: A Case Report and Review of the Literature

The quadricuspid aortic valve (QAV) is a rare malformation; often isolated, sometimes associated with other heart diseases. Before the era of echocardiography, the diagnosis was made incidentally at autopsy or during surgery of valve replacement. The extensive use of echocardiography has allowed an early and accurate diagnosis of this malformation. In many cases, the transthoracic approach is suitable for the diagnosis but, transesophageal echocardiography is a tool for the accurate definition of the valve anatomy. This review analyzes, after the presentation of a clinical case, the current knowledge on embryogenesis, classification, diagnosis and clinical course of QAV.

An interesting case of tricuspid aortic valve with a quadricuspid function

Quadricuspid aortic valve (QAV) is a rare congenital heart defect, often related to severe aortic regurgitation, and usually detected by echocardiography or at the time of aortic valve surgery. We report a case of an interesting and extremely rare variant of "false" QAV, detected preoperatively by transthoracic and transesophageal echocardiography, in a severely symptomatic patient, admitted to our hospital for dyspnea. Three leaflets of aortic valve appeared quadricuspid, because the left coronary cusp was divided into 2 parts, as confirmed by MRI and pathology. Most frequently, QAV presents with all 4 leaflets equal in size.

A rare pediatric cardiac anomaly: Quadricuspid aortic valve with aortic regurgitation

A quadricuspid aortic valve is rarely diagnosed in children, but it can be associated with significant aortic regurgitation. It is important for pediatric cardiologists to be aware of this pathologic entity. We present a nine-year-old male, diagnosed with a quadricuspid aortic valve and mild aortic regurgitation.

Quadricuspid aortic valve complicated with infective endocarditis: report of a case

Congenital quadricuspid aortic valve is a rare cardiac malformation with an unknown risk of infective endocarditis. We report a case of quadricuspid aortic valve complicated with infective endocarditis. A 53-year-old Japanese woman was hospitalized with leg edema and a fever of unknown origin. Corynebacterium striatum was detected in the blood culture. Echocardiography demonstrated a quadricuspid aortic valve with vegetation and severe functional regurgitation. The condition was diagnosed as a quadricuspid aortic valve with infective endocarditis, for which surgery was performed. The quadricuspid aortic valve had three equal-sized cusps and one smaller cusp (type B according to Hurwitz classification). We dissected the vegetation and infectious focus and implanted a mechanical valve. Following the case report, we review the literature.

Successful use of a donor heart with quadricuspid aortic valve for orthotopic heart transplantation

Quadricuspid aortic valve (QAV) is a rare congenital anomaly of the aortic valve. We describe transplanting a donor heart with a QAV with successful mid-term outcome.

Quadricuspid aortic valve with ruptured sinus of Valsalva

We present a case of a 24-year-old woman who was diagnosed with quadricuspid aortic valve with ruptured sinus of Valsalva. Quadricuspid aortic valve is a rare congenital cardiac anomaly. The recognition of quadricuspid aortic valve has clinical significance as it causes aortic valve dysfunction, and is often associated with other congenital cardiac abnormalities. We showed the important role of multimodality imaging in diagnosing a quadricuspid aortic valve associated with ruptured sinus of Valsalva.

Evaluation of the aortic and mitral valves with cardiac computed tomography and cardiac magnetic resonance imaging

Cardiac computed tomography (CT) produces high-quality anatomical images of the cardiac valves and associated structures. Cardiac magnetic resonance imaging (MRI) provides images of valve morphology, and allows quantitative evaluation of valvular dysfunction and determination of the impact of valvular lesions on cardiovascular structures. Recent studies have demonstrated that cardiac CT and MRI are important adjuncts to echocardiography for the evaluation of aortic and mitral valvular heart diseases (VHDs). Radiologists should be aware of the technical aspects of cardiac CT and MRI that allow comprehensive assessment of aortic and mitral VHDs, as well as the typical imaging features of common and important aortic and mitral VHDs on cardiac CT and MRI.

Morphological assessment of the aortic valve using coronary computed tomography angiography, cardiovascular magnetic resonance, and transthoracic echocardiography: comparison with intraoperative findings

To compare the diagnostic accuracies of coronary computed tomography angiography (CCTA), cardiovascular magnetic resonance (CMR), and transthoracic echocardiography (TTE) in aortic valve (AV) morphological assessments with operative findings. We retrospectively enrolled 262 patients who underwent CCTA, CMR, and TTE before AV surgery. Two independent blinded observers assessed AV morphology as being tricuspid, bicuspid, or quadricuspid using three imaging modalities. Interobserver and intermodality agreements were obtained with kappa statistics. The diagnostic accuracies of CCTA, CMR, and TTE for identifying AV morphology (tricuspid vs. non-tricuspid) were compared with intraoperative findings as the reference standard. At surgery, tricuspid AV, bicuspid AV, and quadricuspid AV were present in 179, 80, and 3 patients, respectively. The CCTA and CMR image qualities were all diagnostic. Thirteen cases of TTE were not evaluable due to severe AV calcification. An excellent correlation between CMR and CCTA was seen for the identification of AV morphology (κ = 0.97). Good correlations existed between CCTA and TTE (κ = 0.72) and between CMR and TTE (κ = 0.74). CCTA, CMR, and TTE had an excellent or good interobserver agreement (κ = 0.90, 0.95, and 0.72, respectively). Sensitivity, specificity, and positive and negative predictive values for AV morphology assessment (tricuspid vs. non-tricuspid) were: 97, 95, 98, and 94 % with CCTA (n = 262); 98, 96, 98, and 95 % with CMR (n = 262); and 98, 88, 95, and 96 % with TTE (n = 249). CCTA and CMR are highly accurate for identifying AV morphology.

Quadricuspid aortic valve by cardiac magnetic resonance imaging: a case report and review of the literature

Quadricuspid aortic valve (QAV) is a rare congenital cardiac entity. The recognition of QAV has clinical significance as it causes aortic valve dysfunction, commonly aortic regurgitation, and is often associated with other congenital cardiac abnormalities. We showed the important role played by cardiac magnetic resonance imaging in detecting QAV and review the available literature to explain its incidence, diagnosis, classifications, embryology, correlation between morphology of the QAV and its function, associated conditions, and management.

Dynamic evaluation of a quadricuspid aortic valve with coronary computed tomography angiography

A 35-year-old man presented with 9 years of chronic chest pain and was found to have moderate-to-severe aortic regurgitation on echocardiography. Aortic valve morphology on the initial echocardiogram was deemed normal. Computed tomography angiography was obtained for further evaluation of the aortic root dimension and anatomy. In addition to noninvasive evaluation of the coronary arteries, the higher spatial resolution and volumetric coverage of computed tomography angiography can better define the valvular and aortic anatomy. Reconstruction of retrospectively gated cine images through the aortic valve plane revealed a quadricuspid valve with 4 equal-sized cusps. Incomplete coaptation of the aortic valve cusps was seen during diastole, explaining the marked aortic regurgitation. In addition, a dilated ascending thoracic aorta (4.7 cm) was revealed. On the basis of these findings, the patient was treated surgically with a composite valve graft replacement of his aortic root.

Quadricuspid aortic valve with sinus of Valsalva rupture

A 22-year-old female with no medical history presented to the emergency room with 2 weeks of rapidly worsening dyspnea on exertion, orthopnea, and cough. On cardiac auscultation, she was noted to have to-and-fro murmurs and a continuous murmur with signs of right heart failure. Echocardiographic images obtained showed moderate to severe aortic regurgitation, severe tricuspid regurgitation, and a "windsock" originating in the right coronary sinus of Valsalva and terminating in the right atrium. The aortic valve had four leaflets, with the right leaflet function compromised by the ruptured sinus, causing aortic regurgitation. The patient underwent resection of the sinus aneurysm and aortic valve replacement with a bioprosthetic valve. Quadricuspid aortic valves are uncommon and are rarely associated with sinus of Valsalva aneurysm. The prevalence in the general population, clinical progression, and prognosis of this unique congenital abnormality are reviewed.