Advertisement

Congenital aortic and truncal valve reconstruction using the Ozaki technique: Short-term clinical results

Published:February 18, 2020DOI:https://doi.org/10.1016/j.jtcvs.2020.01.087

      Abstract

      Objectives

      Aortic valve reconstruction (AVRec) with neocuspidization or the Ozaki procedure with complete cusp replacement for aortic valve disease has excellent mid-term results in adults. Limited results of AVRec in pediatric patients have been reported. We report our early outcomes of the Ozaki procedure for congenital aortic and truncal valve disease.

      Methods

      A retrospective analysis was performed on all 57 patients with congenital aortic and truncal valve disease who had a 3-leaflet Ozaki procedure at a single institution from August 2015 to February 2019. Outcome measures included mortality, surgical or catheter-based reinterventions, and echocardiographic measurements.

      Results

      Twenty-four patients had aortic regurgitation (AR), 6 had aortic stenosis (AS), and 27 patients had AS/AR. Two patients had quadricuspid valves, 26 had tricuspid, 20 had bicuspid, and 9 had unicusp aortic valves. Four patients had truncus arteriosus. Thirty-four patients had previous aortic valve repairs and 5 had replacements. Preoperative echocardiography mean annular diameter was 20.90 ± 4.98 cm and peak gradient for patients with AS/AR was 53.62 ± 22.20 mm Hg. Autologous, Photofix, and CardioCel bovine pericardia were used in 20, 35, and 2 patients. Eight patients required aortic root enlargement and 20 had sinus enlargement. Fifty-one patients had concomitant procedures. Median intensive care unit and hospital length of stay were 1.87 and 6.38 days. There were no hospital mortalities or early conversions to valve replacement. At discharge, 98% of patients had mild or less regurgitation and peak aortic gradient was 16.9 ± 9.5 mm Hg. Two patients underwent aortic valve replacement. At median follow-up of 8.1 months, 96% and 91% of patients had less than moderate regurgitation and stenosis, respectively.

      Conclusions

      The AVRec procedure has acceptable short-term results and should be considered for valve reconstruction in pediatric patients with congenital aortic and truncal valve disease. Longer-term follow-up is necessary to determine the optimal patch material and late valve function and continued annular growth.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AR (aortic regurgitation), AS (aortic stenosis), AVRec (aortic valve reconstruction), BSA (body surface area), CI (confidence interval), CPB (cardiopulmonary bypass), LVEDV (left ventricular end diastolic volume), LVEDVz (z score of the BSA-indexed left ventricular end diastolic volume)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bacha E.A.
        • McElhinney D.B.
        • Guleserian K.J.
        • Colan S.D.
        • Jonas R.A.
        • del Nido P.J.
        • et al.
        Surgical aortic valvuloplasty in children and adolescents with aortic regurgitation: acute and intermediate effects on aortic valve function and left ventricular dimensions.
        J Thorac Cardiovasc Surg. 2008; 135: 552-559
        • David T.E.
        • Omran A.
        • Ivanov J.
        • Armstrong S.
        • de Sa M.P.
        • Sonnenberg B.
        • et al.
        Dilation of the pulmonary autograft after the Ross procedure.
        J Thorac Cardiovasc Surg. 2000; 119: 210-220
        • Luciani G.B.
        • Barozzi L.
        • Tomezzoli A.
        • Casali G.
        • Mazzucco A.
        Bicuspid aortic valve disease and pulmonary autograft root dilatation after the Ross procedure: a clinicopathologic study.
        J Thorac Cardiovasc Surg. 2001; 122: 74-79
        • Narang S.
        • Satsangi D.K.
        • Banerjee A.
        • Geelani M.A.
        Stentless valves versus stented bioprostheses at the aortic position: midterm results.
        J Thorac Cardiovasc Surg. 2008; 136: 943-947
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Uchida S.
        • Takatoh M.
        • Kiyohara N.
        Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium.
        J Thorac Cardiovasc Surg. 2018; 155: 2379-2387
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Uchida S.
        • Nozawa Y.
        • Matsuyama T.
        • et al.
        Aortic valve reconstruction using self-developed aortic valve plasty system in aortic valve disease.
        Interact Cardiovasc Thorac Surg. 2011; 12: 550-553
        • Baird C.W.
        • Zurakowski D.
        • Bueno A.
        • Borisuk M.J.
        • Raju V.
        • Mokashi S.A.
        • et al.
        Outcomes and short-term follow-up in complex ross operations in pediatric patients undergoing Damus-Kaye-Stansel takedown.
        Semin Thorac Cardiovasc Surg. 2016; 28: 81-89
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Nozawa Y.
        • Takatoh M.
        • Hagiwara S.
        • et al.
        Aortic valve reconstruction using autologous pericardium for patients aged less than 60 years.
        J Thorac Cardiovasc Surg. 2014; 148: 934-938
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Uchida S.
        • Nozawa Y.
        • Takatoh M.
        • et al.
        Aortic valve reconstruction using autologous pericardium for ages over 80 years.
        Asian Cardiovasc Thorac Ann. 2014; 22: 903-908
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Uchida S.
        • Nozawa Y.
        • Takatoh M.
        • et al.
        A total of 404 cases of aortic valve reconstruction with glutaraldehyde-treated autologous pericardium.
        J Thorac Cardiovasc Surg. 2014; 147: 301-306
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Uchida S.
        • Takatoh M.
        • Hagiwara S.
        • et al.
        Aortic valve reconstruction using autologous pericardium for aortic stenosis.
        Circ J. 2015; 79: 1504-1510
        • Cheng A.
        • Dagum P.
        • Miller D.C.
        Aortic root dynamics and surgery: from craft to science.
        Philos Trans R Soc Lond B Biol Sci. 2007; 362: 1407-1419
        • Rodriguez F.
        • Green G.R.
        • Dagum P.
        • Nistal J.F.
        • Harrington K.B.
        • Daughters G.T.
        • et al.
        Left ventricular volume shifts and aortic root expansion during isovolumic contraction.
        J Heart Valve Dis. 2006; 15: 465-473
        • Baird C.W.
        • Myers P.O.
        • del Nido P.J.
        Aortic valve reconstruction in the young infants and children.
        Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2012; 15: 9-19
        • Majeed A.
        • Baird C.
        • Borisuk M.J.
        • Sanders S.P.
        • Padera R.F.
        Histology of pericardial tissue substitutes used congenital heart surgery.
        Pediatr Dev Pathol. 2016; 19: 383-388
        • Zaidi A.H.
        • Nathan M.
        • Emani S.
        • Baird C.
        • del Nido P.J.
        • Gauvreau K.
        • et al.
        Preliminary experience with porcine intestinal submucosa (CorMatrix) for valve reconstruction in congenital heart disease: histologic evaluation of explanted valves.
        J Thorac Cardiovasc Surg. 2014; 148: 2216-2225
        • Schoen F.J.
        • Levy R.J.
        Calcification of tissue heart valve substitutes: progress toward understanding and prevention.
        Ann Thorac Surg. 2005; 79: 1072-1080
        • Duran C.M.
        • Gometza B.
        • Shahid M.
        • Al-Halees Z.
        Treated bovine and autologous pericardium for aortic valve reconstruction.
        Ann Thorac Surg. 1998; 66: S166-S169
        • Al Halees Z.
        • Al Shahid M.
        • Al Sanei A.
        • Sallehuddin A.
        • Duran C.
        Up to 16 years follow-up of aortic valve reconstruction with pericardium: a stentless readily available cheap valve?.
        Eur J Cardiothorac Surg. 2005; 28: 200-205
        • Liu X.
        • Han L.
        • Song Z.
        • Tan M.
        • Gong D.
        • Xu Z.
        Aortic valve replacement with autologous pericardium: long-term follow-up of 15 patients and in vivo histopathological changes of autologous pericardium.
        Interact Cardiovasc Thorac Surg. 2013; 16: 123-128
        • Jeong D.S.
        • Kim K.H.
        • Ahn H.
        Long-term results of the leaflet extension technique in aortic regurgitation: thirteen years of experience in a single center.
        Ann Thorac Surg. 2009; 88: 83-89
        • Saleeb S.F.
        • Gauvreau K.
        • Mayer J.E.
        • Newburger J.W.
        Aortic valve replacement with bovine pericardial tissue valve in children and young adults.
        Circulation. 2019; 139: 983-985
        • Myers P.O.
        • Mokashi S.A.
        • Horgan E.
        • Borisuk M.
        • Mayer Jr., J.E.
        • Del Nido P.J.
        • et al.
        Outcomes after mechanical aortic valve replacement in children and young adults with congenital heart disease.
        J Thorac Cardiovasc Surg. 2019; 157: 329-340
        • Baird C.W.
        • Myers P.O.
        • Piekarski B.
        • Borisuk M.
        • Majeed A.
        • Emani S.M.
        • et al.
        Photo-oxidized bovine pericardium in congenital cardiac surgery: single-centre experience.
        Interact Cardiovasc Thorac Surg. 2017; 24: 240-244
        • Myers P.O.
        • Tissot C.
        • Christenson J.T.
        • Cikirikcioglu M.
        • Aggoun Y.
        • Kalangos A.
        Aortic valve repair by cusp extension for rheumatic aortic insufficiency in children: long-term results and impact of extension material.
        J Thorac Cardiovasc Surg. 2010; 140: 836-844
        • Prabhu S.
        • Armes J.E.
        • Bell D.
        • Justo R.
        • Venugopal P.
        • Karl T.
        • et al.
        Histological evaluation of explanted tissue engineered bovine pericardium (CardioCel®).
        Semin Thorac Cardiovasc Surg. 2017; 29: 356-363
        • Mazzitelli D.
        • Nöbauer C.
        • Rankin J.S.
        • Vogt M.
        • Lange R.
        • Schreiber C.
        Complete aortic valve cusp replacement in the pediatric population using tissue-engineered bovine pericardium.
        Ann Thorac Surg. 2015; 100: 1923-1925
        • Hofferberth S.C.
        • Baird C.W.
        • Hoganson D.M.
        • Quiñonez L.G.
        • Emani S.M.
        • Del Nido P.J.
        • et al.
        Mechanical properties of autologous pericardium change with fixation time: implications for valve reconstruction.
        Semin Thorac Cardiovasc Surg. 2019; 31: 852-854
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • Uchida S.
        • Nozawa Y.
        • Takatoh M.
        • et al.
        Reconstruction of bicuspid aortic valve with autologous pericardium—usefulness of tricuspidization.
        Circ J. 2014; 78: 1144-1151
        • Mayer K.
        • Aicher D.
        • Feldner S.
        • Kunihara T.
        • Schäfers H.J.
        Repair versus replacement of the aortic valve in active infective endocarditis.
        Eur J Cardiothorac Surg. 2012; 42: 122-127
        • Okada K.
        • Inoue Y.
        • Haida H.
        • Suzuki S.
        Aortic valve reconstruction using autologous pericardium (Ozaki procedure) for active infective endocarditis: a case report.
        Gen Thorac Cardiovasc Surg. 2018; 66: 546-548
        • Makkar R.R.
        • Fontana G.
        • Søndergaard L.
        Possible subclinical leaflet thrombosis in bioprosthetic valves.
        N Engl J Med. 2016; 374: 1591-1592
        • Chakravarty T.
        • Søndergaard L.
        • Friedman J.
        • De Backer O.
        • Berman D.
        • Kofoed K.F.
        • et al.
        Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study.
        Lancet. 2017; 389: 2383-2392

      Linked Article

      • Commentary: Ozaki valve reconstruction in children: Is it still a valve replacement?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 5
        • Preview
          An interesting article in the current issue of the Journal by Baird and colleagues1 describes their short-term results with aortic valve reconstruction with neocuspidization (Ozaki technique) in children and young adults. They reported freedom from moderate or greater aortic valve regurgitation of 88% at 2 years, freedom from moderate or greater aortic stenosis of 88% at 2 years, and freedom from reoperation of 91% at 1.5 years, although the number of patients at each time point is unknown. There were no operative deaths and 2 late deaths after discharge.
        • Full-Text
        • PDF
      • Commentary: A pediatric perspective on the Ozaki procedure
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 5
        • Preview
          Baird and colleagues1 describe the first comprehensive application of the Ozaki procedure to a pediatric population. Congenital aortic valve disease is present in up to 2% of the population2 and is a lifelong problem with no discrete cure available. For this reason, management strategies have to be designed in the context of a long life, and there are an increasing number of surgical and interventional options that can be applied to obtain long-term, high-quality palliation. We agree that the Ozaki procedure fits within this paradigm as a surgical technique to help manage congenital aortic valve disease.
        • Full-Text
        • PDF
      • Commentary: Aortic valve reconstruction with neocuspidization—A word of caution?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 5
        • Preview
          The history of cardiac surgery is riddled with examples of failed operations and failed patches, prostheses, and implants.1,2 They typically start on a wave of enthusiasm, sometimes (for pediatric cardiac surgery) as an offshoot of a strong adult experience, such as what we are witnessing here with the aortic valve reconstruction (AVRec) neocuspidization (Ozaki) procedure. This is not necessarily bad, as long as patients do not get hurt, and it sometimes even leads to progress. Provided that these procedures are performed in the proper scientific context and with appropriate scrutiny, as was done in this particular setting of a large academic center, these procedures or implants can morph into better operations for our patients.
        • Full-Text
        • PDF