Commentary: Ozaki valve reconstruction in children: Is it still a valve replacement?

Abstract

Central MessageIt is unknown whether the Ozaki technique for aortic valve reconstruction in children and young adults will provide outcomes similar to those of aortic valve repair or the Ross operation.See Article page 1567. It is unknown whether the Ozaki technique for aortic valve reconstruction in children and young adults will provide outcomes similar to those of aortic valve repair or the Ross operation. See Article page 1567. An interesting article in the current issue of the Journal by Baird and colleagues1Baird C.W. Sefton B. Chavez M. Sleeper L.A. Marx G.A. del Nido P. Congenital aortic and truncal valve reconstruction using the Ozaki technique: short-term clinical results.J Thorac Cardiovasc Surg. 2021; 161: 1567-1577Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar 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. It seems important to emphasize a few points to put this fascinating article into a proper perspective. Because it is always difficult to speculate on whether others would or would not be willing to apply the Ozaki technique to children and young adults, we choose to view the results of Ozaki technique in these patients through the prism of objectivity reflecting on our current practice in Melbourne. First, it should be noted that all but 1 of their 57 patients were aged more than 1 year. It also should be emphasized that children aged more than 1 year are naturally selected to have an aortic valve morphology best suited for repair. In Melbourne, we aim to repair the aortic valve as our first priority. In children aged more than 1 year, freedom from aortic valve reoperation is 90% at 5 years and 74% at 10 years when the valve is of sufficient quality to be repaired without any patch material (Figure 1, A). In children aged more than 1 year, freedom from aortic valve reoperation is 85% at 5 years and 68% at 10 years, when the valve had to be repaired with patch material (Figure 1, B). Additionally, operative mortality for aortic valve repair combined (with and without a patch) was 0.4% (1/238). When the valve is deemed not repairable, in children aged more than 1 year, we perform the Ross operation with a freedom from autograft reoperation of 98% at 5 years and 91% at 10 years (Figure 1, C), and freedom from all reoperations of 92% at 5 years and 78% at 10 years (Figure 1, D), notably, with 0% operative mortality. Thus, would we be inclined to use the Ozaki reconstruction in all our patients aged more than 1 year? Not yet. At this point in time, it is difficult to imagine that the Ozaki reconstruction would provide better results in a growing child. Second, 16% (9/57) were young adults and 30% (17/57) were adolescents aged 13 to 17 years. With 26% (15/57) of patients weighing more than 60 kg, the outcomes in approximately one-quarter of their patients would be expected to be similar to the results achieved in adults and reported by Ozaki and colleagues.2Ozaki 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: 2379-2387Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar,3Ozaki 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: 550-553Crossref PubMed Scopus (77) Google Scholar Ozaki and colleagues2Ozaki 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: 2379-2387Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar recently reported their midterm results in 850 patients who underwent Ozaki aortic valve reconstruction with a mean follow-up time of 53 months. With 15 patients reaching 9 years of follow-up, Ozaki and colleagues2Ozaki 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: 2379-2387Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar reported an overall survival of 85%, a cumulative incidence of reoperation of 4.2%, and a cumulative incidence of moderate or greater aortic regurgitation of 7.3%. Likewise, Wiggins and colleagues4Wiggins L.M. Mimic B. Issitt R. Ilic S. Bonello B. Marek J. et al.The utility of aortic valve leaflet reconstruction techniques in children and young adults.J Thorac Cardiovasc Surg. 2020; 159: 2369-2378Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar used the Ozaki reconstruction in 58 young adults and children with aortic valve disease with a median age of 14.8 years and median follow-up of 14 months. They reported 1 late death.4Wiggins L.M. Mimic B. Issitt R. Ilic S. Bonello B. Marek J. et al.The utility of aortic valve leaflet reconstruction techniques in children and young adults.J Thorac Cardiovasc Surg. 2020; 159: 2369-2378Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar One-quarter of their patients had greater than moderate aortic regurgitation, and 12% of patients required aortic valve reoperation at 3 years.4Wiggins L.M. Mimic B. Issitt R. Ilic S. Bonello B. Marek J. et al.The utility of aortic valve leaflet reconstruction techniques in children and young adults.J Thorac Cardiovasc Surg. 2020; 159: 2369-2378Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Thus, would we be inclined to use Ozaki reconstruction in fully grown adolescents and young adults? No, definitely not at this stage. It would be prudent to await longer-term outcomes, particularly because it must be remembered that the long-term outcomes of the Ross operation in adults are superb.5Buratto E. Shi W.Y. Wynne R. Poh C.L. Larobina M. O’Keefe M. et al.Improved survival after the Ross procedure compared with mechanical aortic valve replacement.J Am Coll Cardiol. 2018; 71: 1337-1344Crossref PubMed Scopus (55) Google Scholar,6Skillington P.D. Mokhles M.M. Takkenberg J.J. Larobina M. O’Keefe M. Wynne R. et al.The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.J Thorac Cardiovasc Surg. 2015; 149: 46-52Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar In Melbourne, survival after the Ross operation in 392 adults was 98% at 10 years and 95% at 20 years,5Buratto E. Shi W.Y. Wynne R. Poh C.L. Larobina M. O’Keefe M. et al.Improved survival after the Ross procedure compared with mechanical aortic valve replacement.J Am Coll Cardiol. 2018; 71: 1337-1344Crossref PubMed Scopus (55) Google Scholar and the freedom from autograft reoperation was 96% at 18 years.6Skillington P.D. Mokhles M.M. Takkenberg J.J. Larobina M. O’Keefe M. Wynne R. et al.The Ross procedure using autologous support of the pulmonary autograft: techniques and late results.J Thorac Cardiovasc Surg. 2015; 149: 46-52Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Third, 7% (4/57) of their patients had truncus arteriosus and 3.5% (2/57) had quadricuspid valve. Clearly, the Ross operation is not feasible in patients with truncus arteriosus. The durability of the truncal valve repair has been poor.5Buratto E. Shi W.Y. Wynne R. Poh C.L. Larobina M. O’Keefe M. et al.Improved survival after the Ross procedure compared with mechanical aortic valve replacement.J Am Coll Cardiol. 2018; 71: 1337-1344Crossref PubMed Scopus (55) Google Scholar We have previously shown that most patients with moderate or greater truncal valve insufficiency and a quadricuspid valve are likely to require truncal valve surgery.7Naimo P.S. Fricke T.A. d’Udekem Y. Brink J. Weintraub R.G. Brizard C.P. et al.Impact of truncal valve surgery on the outcomes of truncus arteriosus repair.Eur J Cardiothorac Surg. 2018; 54: 524-531Crossref PubMed Scopus (19) Google Scholar, 8Konstantinov I.E. Perrier S.L. Naimo P.S. d’Udekem Y. Neonatal quadricuspid truncal valve repair with left coronary artery unroofing.J Thorac Cardiovasc Surg. 2019; 157: 710-711Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 9Naimo P.S. Fricke T.A. Yong M.S. d’Udekem Y. Kelly A. Radford D. et al.Outcomes of truncus arteriosus repair in children: 35-years of experience from a single institution.Semin Thorac Cardiovasc Surg. 2015; 28: 500-511Abstract Full Text Full Text PDF Scopus (50) Google Scholar However, often the diameter of the truncal valve annulus is large, which provides an excellent substrate for tricuspidization of the truncal valve and reduction of the annulus.7Naimo P.S. Fricke T.A. d’Udekem Y. Brink J. Weintraub R.G. Brizard C.P. et al.Impact of truncal valve surgery on the outcomes of truncus arteriosus repair.Eur J Cardiothorac Surg. 2018; 54: 524-531Crossref PubMed Scopus (19) Google Scholar,8Konstantinov I.E. Perrier S.L. Naimo P.S. d’Udekem Y. Neonatal quadricuspid truncal valve repair with left coronary artery unroofing.J Thorac Cardiovasc Surg. 2019; 157: 710-711Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar We have recently reported freedom from truncal valve reoperation of 64% at 10 years after tricuspidization of the quadricuspid truncal valve.10Naimo P.S. Fricke T.A. Lee M.G.Y. d’Udekem Y. Brink J. Brizard C.P. et al.The quadricuspid truncal valve: surgical management and outcomes.J Thorac Cardiovasc Surg. 2021; 161: 368-375Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In fact, freedom from truncal valve reoperation after tricuspidization was superior to truncal valve replacement in children aged less than 6 years, in whom an adult-sized mechanical prosthesis may not be feasible.8Konstantinov I.E. Perrier S.L. Naimo P.S. d’Udekem Y. Neonatal quadricuspid truncal valve repair with left coronary artery unroofing.J Thorac Cardiovasc Surg. 2019; 157: 710-711Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,10Naimo P.S. Fricke T.A. Lee M.G.Y. d’Udekem Y. Brink J. Brizard C.P. et al.The quadricuspid truncal valve: surgical management and outcomes.J Thorac Cardiovasc Surg. 2021; 161: 368-375Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Thus, would we be inclined to use Ozaki reconstruction in children who require truncal valve repair? Perhaps we would, provided that the long-term results of Ozaki reconstruction in children with truncus arteriosus will be better than those after truncal valve replacement. Finally, bovine pericardium was used in 65% (37/57), and autologous pericardium treated with glutaraldehyde was used in 35% (20/57). Thus, the Ozaki reconstruction is still a valve replacement, although with autologous tissue in some patients, with no growth capacity. Therefore, one would not expect that Ozaki valve replacement would give better results compared with other biological tissue valve replacements in a growing child. We must remain pragmatic when approaching the aortic or truncal valve repair. It is fascinating and somewhat bewildering to think that autologous tissue with the ability to regenerate may become available in the future.11Konstantinov I.E. Fricke T.A. Ivanov Y. Porrello E. From bioprosthetic tissue degeneration to regeneration: a new surgical horizon in the era of regenerative medicine.J Thorac Cardiovasc Surg. 2019; 158: 742Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar If Ozaki valve replacement could be modified using autologous tissue with preserved growth capacity and preserved regenerative ability to ensure resistance to calcification, it may prove to be an extremely valuable technique in selected patients. Until then, it will remain a valve replacement with the expected outcomes similar to those of biological prostheses or homografts. Congenital aortic and truncal valve reconstruction using the Ozaki technique: Short-term clinical resultsThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 5PreviewAortic 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. Full-Text PDF