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Figure 1 Cusp Repair Maneuvers

(A) Completed bicuspidalization equalizes free-margin length of the 2 cusps by suture closure of cleft in partially fused conjoint cusp with sufficient tissue. (B) Triangular resection (left 3 panels) or true plication (right panel) for prolapsing cusp with redundant tissue. (C) Shortening of free margin beyond equal length of the 2 cusps (overcorrection) improves competence in case of restriction. (D) Suture or patch closure with autologous pericardium of perforations, fenestrations, and tears. Occasionally, the free margin is reinforced using a running 7-0 polypropylene suture. Regurgitant orifice is delineated by free margin thickening, and cautious shaving is often done.