The Use of the CardioCel 3D 60° Patch for Aortic Arch Reconstruction in Infancy-A Word of Caution

BACKGROUND

There are limited data on outcomes after implantation of the CardioCel 3D 60° patch in great vessel repair. After anecdotally witnessing an increase in negative outcomes, we reviewed our experience using this patch in our neonate and infant patients undergoing aortic arch repair.

METHODS

Aortic arch repair with implantation of the CardioCel 3D 60° patch was performed in 24 patients between July 2018 and July 2021. Dominant cardiac morphologies were hypoplastic left heart syndrome (66%), atrioventricular canal defects (13%), and other (21%). Median age at implantation was 44 days (interquartile range [IQR], 6-112 days). Recurrent obstruction was defined as the need for reoperation or catheter intervention or recurrent peak pressure gradient of descending aorta ≥25 mm Hg on echocardiography.

RESULTS

Five deaths occurred after a median of 217 days (IQR, 69-239 days). Twelve patients (50%) had recurrent obstruction. Three patients (13%) required redo aortic arch operation after a median of 148 days (IQR, 128-193 day), with extensive fibrous coating of the patch interior causing obstruction. Eleven patients (46%) required at least 1 balloon angioplasty on their aorta after a median of 102 days (IQR, 83-130 days) after repair, and 3 needed >1 catheter intervention. The estimated probability of having recurrent obstruction was 85% at 6 months and 71% at the 1-year follow (P = .06).

CONCLUSIONS

Recurrent aortic obstruction occurred in half of our patients shortly after repair. The use of the CardioCel 3D 60° patch for aortic arch reconstruction in neonates and infants should be reevaluated.

Lifetime Management of Adolescents and Young Adults with Congenital Aortic Valve Disease

In this invited expert review, we focus on evolving lifetime management strategies for adolescents and young adults with congenital aortic valve disease, acknowledging that these patients often require multiple interventions during their lifetime. Our goal is to preserve the native aortic valve when feasible. Leveraging advanced multimodality imaging, a detailed assessment of the aortic valve and root complex can be obtained, and a surgically approach tailored to an individual patient's anatomy and pathology can be used. In turn, aortic valve repair and reconstruction can be offered to a greater number of patients, either as a definitive strategy or as a component of a staged strategy to delay the need for aortic valve replacement until later in life when more options are available.

Midterm results after aortic valve neocuspidization

Objectives

Aortic valve neocuspidization with autologous pericardium is gaining increasing attention as a surgical treatment option for aortic valve disease. However, little is known about midterm durability and valve-related events.

Methods

Patients undergoing aortic valve neocuspidization between 2016 and 2021 were included. Transthoracic echocardiography was performed before the operation, at discharge, and annually thereafter. Data were analyzed for incidences of structural valve deterioration, bioprosthetic valve failure, survival, freedom from reoperation, and hemodynamic performance.

Results

A total of 162 patients underwent aortic valve neocuspidization (mean age, 52.6 ± 16.6 years; range, 13-78 years); 114 (70.4%) were male. A total of 132 patients presented with a bicuspid aortic valve (81.5%) and 126 patients presented with aortic valve stenosis (77.8%). Concomitant procedures were performed in 63 patients (38.9%). Mean follow-up was 3.5 ± 1.2 years. At discharge, peak and mean pressure gradients were 15.6 ± 7.2 mm Hg and 8.4 ± 3.7 mm Hg, respectively, with a mean effective orifice area of 2.4 ± 0.8 cm2. After 5 years, peak and mean pressure gradients were 14.5 ± 4.6 mm Hg and 7.5 ± 2.2 mm Hg, respectively, with a mean effective orifice area of 2.3 ± 0.8 cm2. At 5 years, cumulative incidences of moderate and severe structural valve deterioration and bioprosthetic valve failure were 9.82% ± 3.87%, 6.96% ± 3.71%, and 12.1% ± 4.12%, respectively. Survival was 97.3% ± 1.4%, and freedom from reoperation was 91.3% ± 2.4%.

Conclusions

Aortic valve neocuspidization accomplishes low pressure gradients early after initial surgery and during follow-up. Survival in this young patient population is excellent. The main reason for reoperation is endocarditis, and rates for structural valve degeneration are low.

Outcomes post Ozaki procedure among children with aortic valve disease at Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania: a retrospective descriptive study

BACKGROUND

Aortic valve reconstruction using glutaraldehyde-treated autologous pericardium, also called Ozaki procedure, is a surgical procedure for patients with aortic valve disease. Gratifying results have been reported in adult patients, however, limited published data is available in paediatric population. This study looked at clinical characteristics and early outcomes of children who underwent Ozaki procedure at our Institute.

METHODS

This was a retrospective descriptive study conducted on children who underwent aortic valve reconstruction at Jakaya Kikwete Cardiac Institute (JKCI) from January 2019 through December 2022. Medical records of these children were reviewed to extract data on demographics, clinical characteristics, redo surgical interventions and survival.

RESULTS

A total of 10 children underwent Ozaki procedure during the study period. Eight children had severe aortic regurgitation while 2 had severe aortic stenosis preoperatively. All children had either none or trivial aortic regurgitation immediately after surgery. None of them had redone operations throughout the follow-up period. There was no in-hospital mortality, however, one child died one-year after surgery. The mean follow-up period was 1.6 years with the longest follow-up time of 4 years.

CONCLUSION

Ozaki procedure showed encouraging early results among children with aortic valve disease who underwent surgical repair by this technique. Future studies with larger sample sizes and longer follow up periods to evaluate long-term results in this population are recommended.

CardioCel® for repair of congenital heart defects: nationwide results of over 1000 implants

OBJECTIVES

To assess the mid-term performance of CardioCel for the repair of congenital heart defects.

METHODS

Data were retrospectively collected from databases and hospital records in 3 congenital cardiac surgery centres in Australia. Kaplan-Meier curves and log-rank tests were used to test for associations between patient age, gender, patch type and site of implantation. Multivariable Cox regression was used to test whether any specific implantation site was associated with reintervention risk, after adjusting for age group, gender and patch type.

RESULTS

A total of 1184 CardioCel patches were implanted in 752 patients under the age of 18 years. Median age at implant was 12 months [interquartile range (IQR) 3.6-84]. Median follow-up was 2.1 years (IQR 0.6-4.6). Probability of freedom from CardioCel-related reintervention was 93% [95% confidence interval (CI) 91-95] at 1 year, 91% (95% CI 88-93) at 3 years and 88% (95% CI 85-91) at 5 years, respectively. On multivariable regression analysis, aortic valve repair had a higher incidence of reintervention [hazard ratio (HR) = 7.15, P = 0.008] compared to other sites. The probability of reintervention was higher in neonates (HR = 6.71, P = 0.0007), especially when used for augmentation of the pulmonary arteries (HR = 14.38, P = 0.029), as compared to other age groups.

CONCLUSIONS

CardioCel can be used for the repair of a variety of congenital heart defects. In our study, in patients receiving a CardioCel implant, reinterventions were higher when CardioCel was used to augment the pulmonary arteries in neonates and for aortic valve repair as compared to other sites.

Effectiveness and Safety of the Ozaki Procedure for Aortic Valve Disease in Pediatric Patients: A Systematic Review and Meta-Analysis

The surgical treatment options for pediatric aortic valve disease are limited and have debatable long-term durability. In the current situation, the Ross procedure is considered in children for aortic valve disease(s). It is a complex surgical procedure with the risk of neo-aortic dilatation, converting a single valve disease into double valve disease, and associated with future re-interventions. Conversely, the Ozaki procedure has shown promising results in adults. Thus, the present study aimed to provide comparative evidence on the effectiveness and safety of the Ozaki versus Ross procedure for pediatric patients by performing a meta-analytic comparison of reporting outcomes. A total of 15 relevant articles were downloaded and among them, seven articles (one prospective study, five retrospective studies, and one case series) were used in the analysis. Primary outcomes such as physiological laminar flow pattern and hemodynamic parameters, and secondary outcomes such as hospital stays, adverse effects, mortality, and numbers of re-intervention(s) were measured in the meta-analysis. There were no significant differences in the age of patients between children who underwent the Ozaki procedure and those who underwent the Ross procedure at the time of surgeries. The Ozaki procedure is a good solution to an aortic problem(s) similar to the Ross procedure. Unlike the Ross procedure, the Ozaki procedure has restored a physiological laminar flow pattern in the short-term follow-up without the bi-valvular disease. Mean hospital stays (p = 0.048), mean follow-up (p = 0.02), adverse effects (p = 0.02), death, and numbers of re-intervention(s) of children who underwent the Ozaki procedure were fewer than those who underwent the Ross procedure. The time required for re-intervention(s) is higher for children who underwent the Ozaki procedure than those who underwent the Ross procedure. None of the procedures, including the Ozaki procedure for aortic valve disease(s), has significant effects on hemodynamic parameters and the frequent death rate of children after surgeries. Based on our analysis, we may suggest the Ozaki procedure for aortic valve disease surgery in children.

Urgent aortic valve neocuspidization using the Ozaki procedure in an infant with native aortic valve endocarditis

Native valve aortic endocarditis is rarely seen in the paediatric population. Although, the first-line of treatment is medical, surgical intervention may be indicated in patients with unrepairable valvular and subvalvular disease. Recently, the aortic valve neocuspidization (AVNeo) procedure has gained popularity both in adult and children in whom other repair techniques are not feasible. In this case report, we present an urgent aortic valve replacement using the AVNeo technique in a critically ill infant with a small annulus, severe left ventricular outflow tract stenosis, and severe aortic regurgitation.

Aortic valve repair in the pediatric population: emerging role of aortic valve neocuspidization (AVNeo procedure)

Management of aortic valve diseases in children is challenging owing to the quality and quantity of the native tissue for repair, limitations in the currently available biological materials to supplement the repair and to achieve a long-lasting durable repair in an annulus where there is still growth potential. The aortic valve neocuspidization (AVNeo) procedure has emerged as a versatile alternative strategy in the armamentarium of pediatric aortic valve reconstructions that are currently available. In this review article, the focus of the discussion will be on the various aortic valve repair procedures in the pediatric population, with a special emphasis on the emerging role of AVNeo procedure in pediatrics and its outcomes.

Performance of CardioCel in Cardiac Surgery: A Systematic Review

A systematic review was performed for evaluation of the performance of CardioCel^® in cardiac surgery. The review included all studies published from January 2013 to December 2020. We conclude that CardioCel is a strong, flexible tissue substitute with good handling characteristics and a low incidence of thrombosis, aneurysm formation, infection, or structural degeneration. It can be used for a variety of intracardiac and extracardiac repairs of congenital heart defects in all age groups with good durability at mid-term follow-up. However, the use of CardioCel in certain positions requires caution. Information on the long-term performance of CardioCel is lacking.

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.

Calcification Causing Failure of Tissue Engineered Bovine Pericardium After Aortic Valve Repair

CardioCel^® is bovine pericardium which is subjected to a novel tissue engineering process (ADAPT^®) to reduce cytotoxicity and retard calcification while maintaining strength and elasticity. We present a case where CardioCel^® showed rapid degeneration and calcification after repair of an aortic valve.

Aortosubpulmonary Fistula after Konno-Rastan Aortoventriculoplasty

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Degeneration of a Konno patch can result in a complicated aortic pseudoaneurysm.

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Multimodality imaging was required for diagnosis and intraoperative management.

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Peripheral cardiopulmonary bypass and retroplegic cardiac arrestprior to sternotomy can prevent fatal hemorrhage.

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An endovascular aortic occlusion device can be used to “clamp” the aorta.

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Multimodal imaging and a multidisciplinary team were required for optimal results.

Single-Leaflet Aortic Valve Reconstruction Utilizing the Ozaki Technique in Patients With Congenital Aortic Valve Disease

Evaluate outcomes of single leaflet aortic valve reconstruction using Ozaki sizer and template. Single institute retrospective analysis between August 2015 and August 2019. Thirty-three patients, median age 9.3 years and weight 29.2 kg underwent single leaflet Ozaki repair. Preoperative indications were: AR (n = 17), AS (n = 3) or AS/AR (n = 13). Baseline anatomy was unicuspid (n = 15), bicuspid (n = 9) or tricuspid (n = 9). Two patients had endocarditis. Prior interventions included balloon valvuloplasty (n = 22) and aortic valve repair (n = 9). Pre-op average native annulus diameter was 19.6 mm and peak echo gradient was 36 mm Hg. Autologous pericardium, Photofix and CardioCel bovine pericardium were used in 26, 5, and 2 patients. Non-coronary sinus enlargement was required in 3 and aortic root reduction in 9 patients. Single leaflet reconstruction was done for the right coronary cusp (n = 25), non-coronary cusp in (n = 6) and left coronary cusp (n = 2). Additional procedures were done in 30 patients. Median ICU and hospital LOS were 2.1 and 6.3 days. There were no early re-interventions or conversions to valve replacement and one unrelated mortality.en At discharge, all patients had < moderate AR and/or AS with average peak gradients of 15 mm Hg. The median follow-up was 1.1 year, (IQR 0.7-1.8 years). Freedom from ≥ moderate AR and AS at 2 years was 76% and 86%. One patient required surgical re-intervention for severe AR 1.5 years after surgery for inflammatory infiltrate with calcification and fibrosis. Single-leaflet aortic valve leaflet reconstruction utilizing the Ozaki technique has promising early results and can be considered in patients when there are acceptable native leaflets.

Aortic valve neocuspidization with autologous pericardium in adult patients: UK experience and meta-analytic comparison with other aortic valve substitutes

OBJECTIVES

We sought to provide further evidence on the safety and efficacy of aortic valve neocuspidization (AVNeo) using autologous pericardium in adult patients with aortic valve disease by reporting clinical and echocardiographic results from the first UK experience and performing a meta-analytic comparison with other biological valve substitutes.

METHODS

We reported clinical and echocardiographic outcomes of 55 patients (mean age 58 ± 15 years) undergoing AVNeo with autologous pericardium in 2 UK centres from 2018 to 2020. These results were included in a meta-analytic comparison between series on AVNeo (7 studies, 1205 patients, mean weighted follow-up 3.6 years) versus Trifecta (10 studies, 8705 patients, 3.8 years), Magna Ease (3 studies, 3137 patients, 4.1 years), Freedom Solo (4 studies, 1869 patients, 4.4 years), Freestyle (4 studies, 4307 patients, 7 years), Mitroflow (4 studies, 4760 patients, 4.1 years) and autograft aortic valve (7 papers, 3839 patients, 9.1 years).

RESULTS

In the present series no patients required intraoperative conversion. After mean follow-up of 12.5 ± 0.9 months, 3 patients presented with endocarditis and 1 required reintervention. The remaining patients had absent or mild aortic valve insufficiency with very low peak and mean transvalvular gradients (16 ± 3.7 and 9 ± 2.2 mmHg, respectively). Meta-analytic estimates showed non-significant difference between AVNeo and all but Magna Ease valves with regards to structural valve degeneration, reintervention and endocarditis. When compared Magna Ease valve, AVNeo and other valve substitutes showed an excess of valve-related events.

CONCLUSIONS

AVNeo is safe, associated with excellent haemodynamic profile. Its midterm risk of valve-related events is comparable to most biological valve substitutes. Magna Ease is potentially the best biological choice as far as risk of reintervention is concerned.

Pulmonary artery augmentation using decellularized equine pericardium (Matrix Patch™): initial single-centre experience

OBJECTIVES

The aim of this study was to report our initial experience when using Matrix Patch™ a cell-free equine-derived pericardium for the augmentation of branch pulmonary arteries (PAs) in children.

METHODS

Between September 2016 and September 2019, Matrix Patch was used for the augmentation of branch PAs in 96 patients and implanted in 147 separate locations. The median age at implantation was 3.2 years (interquartile range: 0.9-8.4), and 33% of patients were infants. The patch was used mainly in redo surgeries (89.6%). Intra-procedural feasibility and reinterventions were analysed. Primary end points were death or patch-related reoperation/stent implantation. Explanted patches were stained for recellularization/calcification, or to reveal proliferation/inflammation.

RESULTS

A total of 81 patients, who received patches in 119 separate locations, were followed within a median of 20 months (interquartile range: 10.2-30.2). Patients with early reoperation/stent implantation were excluded from follow-up. No patch-related death was noted. Survival at last follow-up was 88% (95% CI: 78.8-93.7%). Overall probability of freedom from reoperation/stent implantation per location, 12 and 24 months after initial surgery was 85.8% (95% CI: 76.2-91.7%) and 78.7 (95% CI: 65.9-87.2%), respectively. At 20 months, superficial proliferation with discrete macrophage activity was seen in explants; however, no signs of calcification are observed.

CONCLUSIONS

The initial experience with the Matrix Patch in PAs showed comparable results to other xenogeneic patch materials. Long-term follow-up data are needed to prove the desired durability of the patch in different locations.

Aortic valve neocuspidalization in paediatric patients with isolated aortic valve disease: early experience

OBJECTIVES

There is growing interest in the aortic valve (AV) neocuspidalization technique for the treatment of aortic valve disease (AVD). We report our medium-term results with this procedure performed in a paediatric patient population.

METHODS

Between July 2016 and May 2020, 22 patients with both congenital and acquired isolated AVD were treated with neocuspidalization. The primary outcome was progression of the preoperatively assessed AVD in the immediate postoperative course and at follow-up. Secondary outcome was freedom from reintervention by material used. Potential predictors of failure were analysed in relation to the primary outcome.

RESULTS

The median age at operation was 13.9 (interquartile range, 9.8-16.2) years, and the prevailing AV defect was stenosis in 10 cases (45%) and incompetence in 12 (55%). Pre-treated autologous pericardium was used in 13 patients whereas bovine pericardium in 9. Effective treatment of AV stenosis or regurgitation was achieved and remained stable over a median follow-up of 11.3 (4.7-21) months. Three patients required AV replacement at 4.9, 3.5 and 33 months. At follow-up, an upward trend of both median indexed vena contracta jet widths and aortic peak and mean gradients were recorded, the latter associated with a failure to grow the aortic annulus. Predictor of such outcome turned out to be the use of bovine pericardium. A significant inverse linear correlation between AV peak gradient at follow-up and preoperative aortic annular size (P = 0.008) was also demonstrated.

CONCLUSIONS

The Ozaki procedure is safe and effective in paediatric patients with AV disease. The use of heterologous pericardium should probably be minimized. Moreover, preoperative small aortic annuli should probably be promptly treated by means of an associated ring enlargement procedure.

Aortic Valve Neocuspidization In a Pulmonary Autograft

Management of aortic valve (AV) disease in the pediatric population is challenged by a lack of attractive valve replacement options. The Ross procedure has been prominent for these patients, however long-term reports have revealed concerns, namely neo-aortic root dilation and regurgitation. More recently, AV neocuspidization (AVNeo) has emerged as an alternative to the Ross operation or other valve replacement procedures in pediatric patients with congenital AV disease. We report the first successful case of AVNeo of a previously implanted pulmonary autograft.

Blood flow characteristics after aortic valve neocuspidization in paediatric patients: a comparison with the Ross procedure

Aims

The aortic valve (AV) neocuspidization (Ozaki procedure) is a novel surgical technique for AV disease that preserves the natural motion and cardiodynamics of the aortic root. In this study, we sought to evaluate, by 4D-flow magnetic resonance imaging, the aortic blood flow characteristics after AV neocuspidization in paediatric patients.

Methods and results

Aortic root and ascending aorta haemodynamics were evaluated in a population of patients treated with the Ozaki procedure; results were compared with those of a group of patients operated with the Ross technique. Cardiovascular magnetic resonance studies were performed at 1.5 T using a 4D flow-sensitive sequence acquired with retrospective electrocardiogram-gating and respiratory navigator. Post-processing of 4D-flow analysis was performed to calculate flow eccentricity and wall shear stress. Twenty children were included in this study, 10 after Ozaki and 10 after Ross procedure. Median age at surgery was 10.7 years (range 3.9–16.5 years). No significant differences were observed in wall shear stress values measured at the level of the proximal ascending aorta between the two groups. The analysis of flow patterns showed no clear association between eccentric flow and the procedure performed. The Ozaki group showed just a slightly increased transvalvular maximum velocity.

Conclusion

Proximal aorta flow dynamics of children treated with the Ozaki and the Ross procedure are comparable. Similarly to the Ross, Ozaki technique restores a physiological laminar flow pattern in the short-term follow-up, with the advantage of not inducing a bivalvular disease, although further studies are warranted to evaluate its long-term results.

Aortic valve neocuspidization with in-body tissue-engineered autologous membranes: preliminary results in a long-term goat model

OBJECTIVES

Aortic valve neocuspidization has shown satisfactory clinical outcomes; however, autologous pericardium durability is a concern for young patients. This study applied an autologous collagenous membrane (Biosheet®), produced by in-body tissue architecture, to aortic valve neocuspidization and investigated its long-term outcome in a goat model.

METHODS

Moulds were embedded subcutaneously in 6 goats. After 2 months, Biosheets formed in the moulds. We performed aortic valve neocuspidization using a portion of the sheets with a thickness of 0.20-0.35 mm, measured by optical coherence tomography. Animals were subjected to echocardiography and histological evaluation at 6 months (n = 3) and 12 months (n = 3). As a control, the glutaraldehyde-treated autologous pericardium was used in 4 goats that were similarly evaluated at 12 months.

RESULTS

All animals survived the scheduled period. At 6 months, Biosheets maintained valve function and showed a regeneration response: fusion to the annulus, cell infiltration to the leaflets and appearance of elastic fibres at the ventricular side. After 12 months, the regenerative structure had changed little without regression, and there was negligible calcification in the 1/9 leaflets. However, all cases had one leaflet tear, resulting in moderate-to-severe aortic regurgitation. In the pericardium group, three-fourths of the animals experienced moderate-to-severe aortic regurgitation with a high rate of calcification (9/12 leaflets).

CONCLUSIONS

Biosheets may have regeneration potential and anti-calcification properties in contrast to autologous pericardium. However, in order to obtain reliable outcome, further improvements are required to strictly control and optimize its thickness, density and homogeneity.

Single center 5-years' experience of Ozaki procedure: mid-term follow-up

BACKGROUND

The Ozaki procedure is an innovative surgical technique aiming at the reconstruction of the aortic valve with autologous pericardium to overcome the limitations of commercially available prostheses.

METHODS

We retrospectively analysed 71 patients who underwent Ozaki operation at our centre between October 2014 and February 2020.

RESULTS

No in-hospital death occurred. Freedom from major adverse valve-related events (MAVRE) was 97%. The aortic gradients and transvalvular velocity are significantly lower at the 3-months echocardiographic control than at the pre-discharged echocardiography (10.93 ± 5.38, p= 0,0003 vs 16.24 ± 7.67 p= 0,0004 respectively). The median follow-up period was 20.7 months (range 2 to 47 months). Four patients showed mild/moderate aortic insufficiency (5.6%) and none showed severe aortic valve insufficiency. No patients underwent reoperation.

CONCLUSIONS

Mid-term outcome follow-up of Ozaki procedure showed optimal results in term of mortality, transaortic valve gradients, freedom from MAVRE and recurrence of aortic valve insufficiency.

Modified Ozaki Procedure Including Annular Enlargement for Small Aortic Annuli in Young Patients

BACKGROUND

Aortic valve neocuspidization (AVNeo) (Ozaki procedure) has excellent midterm results in adults. Outcomes in patients with a small native aortic annulus are unknown. We report early outcomes in young patients with small native aortic valve annuli.

METHODS

Retrospective data of patients undergoing AVNeo between 2015 and 2019 were reviewed. Patients with native aortic annulus less than 21 mm undergoing 3-leaflet AVNeo were included.

RESULTS

A total of 51 patients were identified (median age 7.9 years; median weight 21 kg), and 80% patients were less than or equal to 12 years age. Preoperative indication was aortic regurgitation (AR) (n = 23), aortic stenosis (AS) (n = 22), or mixed AS and AR (n = 6). Baseline anatomy was quadricuspid (n = 1), tricuspid (n = 23), bicuspid (n = 15), or unicuspid (n = 12) valve. Preoperative peak gradient for AS and mixed AS and AR patients was 55.36 mm Hg. Median native annulus diameter was 17 mm; sinus and annular enlargements were required in 22 patients and 9 patients, respectively. Median intensive care unit and hospital length of stay were 2.0 days and 7.2 days, respectively. There were no reinterventions, and there was 1 hospital mortality unrelated to aortic valve. At discharge, 94% of patients had less than or equal to mild AR, and the median peak gradient was 18 mm Hg. At mean follow-up of 11.9 months, 80% and 82% of patients had less than moderate AR and AS, respectively. Three patients required surgical reintervention. In annular enlargement patients, mean annulus Z score remained greater than 0 at follow-up.

CONCLUSIONS

The Ozaki procedure has acceptable short-term results in young patients with small aortic annuli. A larger aortic annulus can be achieved with surgical annular enlargement. Long-term follow-up is necessary to determine late valve function and potential continued annular growth.

Aortic valve neo-cuspidation using the Ozaki technique for acquired and congenital disease: where does this procedure currently stand?

The surgical treatment options for pediatric aortic valve disease are limited. The Ozaki procedure, which involves templated creation of new aortic valve leaflets, has proved to be a promising surgical technique. This review aims at elaborating the indications, technical intricacies, and outcomes of the aortic valve neo-cuspidization procedure (Ozaki procedure) in the pediatric population.