A ten-year-old girl with history of rheumatic fever for eight years presented with worsening dyspnea upon exertion in the prior four to five months with NYHA class III heart failure. Surgeons found that the patient’s anterior mitral valve leaflet was thickened, she had a doming posterior mitral valve leaflet with restricted mobility, and she had moderate to severe mitral regurgitation. The patient’s mitral valve annulus was 40 mm.Surgeons also found thickened aortic valve leaflets with retracted and a deficient left coronary cusp. The patient had severe aortic regurgitation, diastolic flow reversal in the abdominal aorta, and a dilated left ventricle with good left ventricle function. The aortic annulus was 25 mm. Based on this information, the team planned for mitral valve repair with aortic valve repair.The SurgeryAfter a sternotomy, the pericardium was harvested and fixed in 0.6 percent glutaraldehyde, and cardiopulmonary bypass was established between the aorta and bicavae. The mitral valve was addressed by performing peeling of AML. The A2 to A3 segment was tethered, fenestration was performed, secondary chordate were released, and a 30 mm annuloplasty ring was placed by supraseptal approach.When the aortic valve was assessed, the leaflets were observed to be thickened and retracted with rheumatic etiology. The decision was made to perform neocuspidization of aortic leaflets with glutaraldehyde treated pericardium.To perform the neocuspidization, surgeons used a formula inspired by Dr. Praveen Tambrallimat with few modifications (1). They used an additional 5 mm for height and width of the leaflet instead of 1-2 mm for suturing of newly made aortic leaflets. As the height of coaptation is said to be the marker for long term success rate, the team used the additional 1-2 mm as the height and width of leaflets. They were not able to achieve the coaptation height of more than 10 mm. If they had used the additional 5 mm, they could have achieved the coaptation height to be more than 10 mm.With the help of a valve sizer, the aortic annulus was measured to be 25 mm. With the help of silk thread, the leaflets’ length at the level of annulus was also measured. The formula for making new leaflets—the size of the annulus plus 5 mm—was used as marker for the height and width of the leaflets. For the bicuspid valves, the team divided the annulus into three equal parts and made neocommisures. Using these measurements, three cusps were created. In this case, the...