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Aortic insufficiency in a patient with a quadricuspid aortic valve and abnormal left coronary ostium

A 64-year-old female had symptomatic severe aortic insufficiency and was taken up for aortic valve replacement. The patient was found to have a quadricuspid aortic valve and abnormally located early bifurcated left coronary ostium which were very near to the commissures. There is a risk of damaging the coronary ostia while excising the valve or the prosthetic valve can obstruct the abnormally located ostia. Intraoperative transesophageal echocardiography can help in making an accurate intraoperative diagnosis and deciding aortotomy incision and valve excision. This patient underwent successful aortic valve replacement taking great care to save the abnormally located left coronary ostium.