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

Abstract

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.

Keywords: aortic insufficiency; aortic regurgitation; aortic valve repair; aortic valve replacement; cardiovascular imaging; echocardiography; quadricuspid aortic valve; valvular heart disease.

Figure 1. Electrocardiogram

The patient’s electrocardiogram on admission, evidencing sinus tachycardia.

Figure 2. Quadricuspid Aortic Valve Imaging

Panel A shows transthoracic echocardiography demonstrating the quadricuspid aortic valve in a closed position with leaflets approximated, in the parasternal short axis view; note the leaflet sizes with one large cusp, two equally sized cusps, and one small cusp, indicative of Hurwitz and Roberts class D. Panel B demonstrates the quadricuspid aortic valve in the open position in the parasternal short axis view. Interestingly, in this view the valve morphology appears bicuspid. Panel C demonstrates the quadricuspid aortic valve parasternal long axis view, demonstrating the lack of aortic regurgitation, evidencing appropriate approximation of the valve leaflets upon closure.