Autologous pericardial aortic valve reconstruction: early results and comparison with mechanical valve replacement

Examining the application of the IDEAL framework in the reporting and evaluation of innovative invasive procedures: secondary qualitative analysis of a systematic review

OBJECTIVES

The development of new surgical procedures is fundamental to advancing patient care. The Idea, Developments, Exploration, Assessment and Long-term (IDEAL) framework describes study designs for stages of innovation. It can be difficult to apply due to challenges in defining and identifying innovative procedures. This study examined how the IDEAL framework is operationalised in real-world settings; specifically, the types of innovations evaluated using the framework and how authors justify their choice of IDEAL study design.

DESIGN

Secondary qualitative analysis of a systematic review.

DATA SOURCES

Citation searches (Web of Science and Scopus) identified studies following the IDEAL framework and citing any of the ten key IDEAL/IDEAL_D papers.

ELIGIBILITY CRITERIA

Studies of invasive procedures/devices of any design citing any of the ten key IDEAL/IDEAL_D papers.

DATA EXTRACTION AND SYNTHESIS

All relevant text was extracted. Three frameworks were developed, namely: (1) type of innovation under evaluation; (2) terminology used to describe stage of innovation and (3) reported rationale for IDEAL stage.

RESULTS

48 articles were included. 19/48 described entirely new procedures, including those used for the first time in a different clinical context (n=15/48), reported as IDEAL stage 2a (n=8, 53%). Terminology describing stage of innovation was varied, inconsistent and ambiguous and was not defined. Authors justified their choice of IDEAL study design based on limitations in published evidence (n=36) and unknown feasibility and safety (n=32) outcomes.

CONCLUSION

Identifying stage of innovation is crucial to inform appropriate study design and governance decisions. Authors' rationale for choice of IDEAL stage related to the existing evidence base or lack of sufficient outcome data for procedures. Stage of innovation was poorly defined with inconsistent descriptions. Further work is needed to develop methods to identify innovation to inform practical application of the IDEAL framework. Defining the concept of innovation in terms of uncertainty, risk and degree of evidence may help to inform decision-making.

The Ozaki Procedure: Standardized Protocol Adoption of a Complex Innovative Procedure

Background

The Ozaki procedure using autologous pericardium is an interesting but complex alternative for aortic valve replacement. We present a standardized approach to minimize the learning curve and confirm reproducibility.

Methods

After careful preparation, from May 2015 to February 2021, an Ozaki procedure was performed on 46 patients age 51 ± 14 years. Seven had unicuspid (15%), 29 bicuspid (63%), and 10 tricuspid (22%) aortic valves, and 2 patients had endocarditis. Endpoints were operative learning curves, perioperative outcomes, intermediate-term valve hemodynamics, reintervention, health-related quality of life (MacNew Heart Disease Health-Related Quality of Life questionnaire), and mortality.

Results

Cardiopulmonary bypass and aortic clamp times decreased from 145 to 125 ​minutes and 120 to 100 ​minutes, respectively, over the first 20 cases, reflecting the learning curve. There was no major perioperative morbidity or mortality. Median postoperative stay was 6.9 days. Aortic regurgitation was mild or less in all but 2 patients who developed moderate aortic regurgitation. Mean aortic valve gradient was 7.9 mmHg postoperatively, 9.2 mmHg by 6 months, and constant thereafter. Left ventricular ejection fraction was 58% preoperatively, 60% at 6 months, and remained stable thereafter. One patient developed infective endocarditis 7 months postoperatively, failed medical management, and underwent valve replacement at 14 months. Two-year survival was 96%, with 1 noncardiac death at 16 months. Health-related quality of life in mental, physical, and emotional domains was better than matched norms, global 6.2 vs. 5.0 (p < 0.0001).

Conclusions

Using a well-prepared standardized approach, the Ozaki procedure is reproducible with a short learning curve, excellent hemodynamic performance, and good quality of life.

Single center two years' experience of Ozaki procedure: Early follow-up

The Ozaki Procedure is an innovative surgical technique aiming of aortic valve neocuspidization using glutaraldehyde-treated autologous pericardium was first developed by Ozaki et al in 2007. With this newly developed technique, valve replacement was achieved without using prosthetic material due to both aortic stenosis and aortic insufficiency. Between December 2020 and December 2022, a total of 59 patients were operated on with the Ozaki Procedure due to aortic valve pathologies in our center. We evaluated the pre- and postoperative as well as the first-month data of a total of 44 patients with isolated the Ozaki Procedure and compared their echocardiographic changes. Patients with isolated aortic valve pathology were included in the study. Fifteen patients who underwent simultaneous coronary artery bypass surgery and Ozaki Procedure were excluded from the analysis. In the first month after the operation, n:2 (%4.5) patients died. When the preoperative and postoperative 1st month echocardiographic data of the remaining patients were compared, it was found that the decrease in mean gradient, max gradient and peak velocity values in the aortic valve was statistically significant. This is due to the fact that reaching neo-valves has very similar hemodynamics to the native aortic valve. Aortic valve neocuspidization by Ozaki Procedure may be a viable alternative to both surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation. Its popularity and application is increasing all over the world. Short and mid-term results are available in the literature. The short and mid-term results are good, and the long-term results are hopeful.

Computed tomography-guided aortic valve neocuspidization: details of preoperative assessment and surgical technique

The original Ozaki technique involves sizing and trimming the neovalve cusps during cross-clamp. It leads to prolongation of the ischaemic time, as compared to standard aortic valve replacement. We use preoperative computed tomography scanning of the patient's aortic root to develop personalized templates for each leaflet. With this method, autopericardial implants are prepared before the initiation of the bypass. It permits maximally adopting the procedure to the patient's individual anatomy and to shorten the cross-clamp time. We present a case of a computed tomography-guided aortic valve neocuspidization and concomitant coronary artery bypass grafting with excellent short-term results. We discuss the feasibility and technical details of the novel technique.

Aortic valve neocuspidization using the Ozaki technique: A meta-analysis of reconstructed patient-level data

BACKGROUND

Aortic valve neocuspidization using the Ozaki technique has shown promising results both in adults and children.

METHODS

A systematic search of the PubMed and Cochrane databases was performed up to November 13, 2021. Individual patient data were reconstructed and analyzed from the Kaplan-Meier curves of all eligible studies for time-to-event outcomes.

RESULTS

We included a total of 22 studies reporting on 1,891 patients that underwent Ozaki reconstruction. Mean age at the time of surgery was 43.2 ± 24.5 years (65 ± 12.3 years for adult patients and 12.3 ± 3.8 years for pediatric patients). The most common indication was aortic stenosis (46.4%, 95% CI 34.1-58.6). Mean cross-clamp and cardiopulmonary bypass duration were 106.8 ± 24.8 minutes and 135.2 ± 35.1 minutes, respectively. Permanent pacemaker was implanted in 0.7% (95% CI 0.4-1.2) of the patients. At discharge, mean effective orifice area was 2.1 ± 0.5 cm²/m². At latest follow-up, peak gradient was 15.7 ± 7.4 mm Hg and only 0.25% (95% CI 0-2.3) had moderate aortic insufficiency. In-hospital mortality was 0.7% (95% CI 0.1-1.7). Late mortality was 1.9% during a mean follow-up of 38.1 ± 23.8 months. One-year, 3-year, and 5-year freedom from reoperation rates were 98.0 %, 97.0 % and 96.5%, respectively. More than half of the reoperations were due to infective endocarditis (51.5%, 95% CI 18.3-84.0). In our cohort, the risk of endocarditis per patient per year was 0.5%.

CONCLUSIONS

The midterm outcomes of the Ozaki procedure are excellent in terms of hemodynamics, survival, and freedom from reoperation. Acquiring long-term follow-up will help solidify this technique in the cardiac surgery armamentarium.

Auto-Pericardial Mitral Valve Implantation: A Pilot Study

INTRODUCTION

Developing nations continue to grapple with rheumatic heart disease, particularly in the young. There is a need for an alternative to prosthetic mitral valve replacement in irreparable mitral valves, which avoids the need for anticoagulation and risks of thromboembolism.

METHODS

Twelve (12) patients with irreparable severe mitral valve disease underwent auto-pericardial mitral valve implantation from August 2020 to February 2021. The mitral valve leaflets were excised. Autologous pericardium treated with 0.5% glutaraldehyde for 8 minutes was fashioned into anterior and posterior mitral leaflets as per the dimensions on an indigenously designed template based on the studies by Ranganathan and Lam. The pericardial leaflets were sutured onto an appropriately sized mitral annuloplasty ring. The ring with the leaflets was implanted onto the mitral annulus. The leaflets were supported with neo-chordae prepared with Gore-Tex (W L Gore and Associates, Inc. Newark, DE, USA) and polyester sutures to mimic a repaired mitral valve in its structure and dynamics.

RESULTS

The mean cross-clamp time was 138±21.7 minutes. None of the patients required re-exploration. On the third postoperative day, a mean mitral valve orifice area of 3±0.47 cm and mean mitral valve gradient of 2±1.04 were observed. None of the patients had any more than 1+ mitral regurgitation. None of them have required a re-intervention for mitral insufficiency to date.

DISCUSSION

Auto-pericardial mitral valve re-implantation is a safe and effective procedure for severe, irreparable, mitral valve pathologies. However, the mid-term and long-term results need to be compared with conventional mitral valve replacement with a prosthetic valve in a randomised controlled trial.