Aortic Valve Neocuspidization Research Articles

Minimally invasive aortic valve neocuspidization using autologous pericardium – first experience

Highlights. Conducting minimally invasive aortic valve neocuspidization using autologous pericardium is a difficult task due to pericardial harvesting. Thoracoscopic harvesting of the pericardium provides a pericardial patch of sufficient size under visual control. Thus, thoracoscopic pericardial harvesting can transfer all advantages of minimally invasive cardiac surgery to aortic valve neocuspidization using autologous pericardium.Abstract. Minimally invasive aortic valve (AV) replacement is associated with a decrease in the traumatic nature of the procedure, the length of hospital stay, severity of pain, and provides faster rehabilitation and better cosmetic look compared to the gold standard incision in cardiac surgery –median sternotomy. AV neocuspidization using autologous pericardium is safe, associated with excellent hemodynamic parameters in short- and medium-term follow up. However, this technique requires a large pericardial patch to later form new leaflets, thus complicating the use of minimally invasive approach with this type of intervention. We have addressed this issue by introducing thoracoscopic pericardial harvesting. We report two successful cases of minimally invasive AV neocuspidization using autologous pericardium harvested through a thoracoscopic approach with peripheral cardiopulmonary bypass.

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.

Aortic Valve Neocuspidization Procedure Provides Better Postoperative Outcomes When Compared to Rapid Deployement Aortic Valves

The aim of this study was to compare the early results of rapid deployment aortic valves (RD-AVR) and aortic valve neocuspidization (AVNeo) techniques. Between December 2019 to May 2022, 104 patients were operated on with aortic stenosis by RD-AVR (N = 52) and AVNeo (N = 52) techniques. Patients with isolated aortic valve stenosis and aortic stenosis concomittant with planned other cardiac surgeries were included. The mean age of patients in the RD-AVR and AVNeo groups were 67.4 ± 7.8 vs. 62.9 ± 8.7, respectively. Aortic cross-clamp time in the RD-AVR group was 56.7 ± 23.3 minutes, while it was 104.1 ± 27.9 minutes in the AVNeo group (P < 0.001). Cardiopulmonary bypass time in the RD-AVR group and in the AVNeo group was 89.8 ± 27.6 minutes and 141.8 ± 36.7 minutes, respectively (P < 0.001). Permanent pacemaker become necessary in four patients in the RD-AVR group secondary to type 2 AV block. Paravalvular leak was observed in six patients, who underwent RD-AVR, while grade 2 central aortic regurgitation was observed in one patient in the AVNeo group. Hospital mortality was 8% in the RD-AVR group and 6% in the AVNeo group (P = 0.696). AVNeo procedure is a feasible technique in all age groups of patients with successful hemodynamic results in the early postoperative period and with the advantage of not requiring anticoagulants. It also can be applied with other cardiac surgical interventions.

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.

Predictors of Mid-Term AVNeo Insufficiency.

Aortic stenosis (AS) is the most common valvular heart disease and the most common indication for aortic valve replacement in adults. Aortic valve neocuspidization (AVNeo) with fixed autologous pericardium, also known as the Ozaki procedure, is a possible alternative treatment of AS. Autopericardial valves save the dynamics and physiological anatomy of the aortic root, however, the service life of autopericardial leaflets is limited. There is no data about factors that may influence the development of AVNeo insufficiency. Here, we assessed the effect of autopericardial leaflet symmetry on the development of aortic insufficiency after Ozaki procedure. This study included 381 patients with AS who underwent Ozaki procedure. Patients were divided into group 1 (171 patients with symmetric aortic root) and group 2 (210 patients with asymmetric aortic root). The maximum observation period was up to 65 months. Sixteen cases of aortic insufficiency were detected in group 1, and 33 cases were detected in group 2. Based on the results of Cox regression, the predictors of aortic insufficiency in the late postoperative period are age and asymmetry of neocusps. According to results of Kaplan-Meier analysis, insufficiency of AVNeo in the maximum follow-up period after surgical correction of AS for group 1 patients was significantly lower than for group 2 patients (P=0.006). Asymmetric neocusps increase the risk of aortic insufficiency in the mid-term period after Ozaki procedure. And the older the patients at the time of surgery, the less likely they develop AVNeo insufficiency.

Беременность и роды после неокуспидализации аортального клапана аутологичным перикардом: альтернативное решение, не требующее антикоагулянтной терапии

With the development of cardiac surgery, more and more women with congenital heart disease undergo cardiac interventions and reach reproductive age. Therefore, the number of pregnant patients with significant cardiac pathology is increasing. This article presents a clinical case of successful surgical treatment of aortic stenosis (the Ozaki procedure) in a 31-year-old woman who subsequently became pregnant and delivered a child. Conclusion. Despite the debate among cardiac surgeons, the Ozaki procedure can be considered as a viable option for aortic valve replacement in women with the prospect of pregnancy and childbirth. However, a larger study in this population is needed. Key words: aortic valve, aortic stenosis, aortic valve neocuspidization with autologous pericardium, aortic valve replacement, Ozaki procedure, pregnancy

A Case of Severe Aortic Stenosis after Aortic Valve Neocuspidization Using Autologous Pericardium (Ozaki Procedure).

A 56-year-old man with a history of left nephrectomy for Wilms' tumor on chronic hemodialysis underwent aortic valve neocuspidization using autologous pericardium (Ozaki procedure) for aortic stenosis (AS) due to a bicuspid aortic valve 6 years ago. The AS gradually progressed and a decrease in the left ventricular ejection fraction was observed. Because of this, we decided to perform reoperative aortic valve replacement using a mechanical valve. Intraoperative findings showed severe calcification at the site where the autologous pericardium was sutured to the annulus. However, the degeneration of the valve leaflets themselves was mild. While excellent mid-term results have been reported for the Ozaki procedure, the long-term results are still unclear. In this case, the annulus was severely calcified, which reduced the mobility of the leaflet. We report the first case of AS progression requiring reoperation in the long-term period after the Ozaki procedure.

Computational mimicking of surgical leaflet suturing for virtual aortic valve neocuspidization

Abstract The aortic valve neocuspidization (AVNeo) procedure requires the design of patient-specific neo-cusps which can be made numerically through the neovalve closure modelling. Prior the simulation, it is required to ‘suture virtually’ the neocusps into the patient’s aortic geometry, i.e., to find such state in which the neocusps are placed in the aortic root lumen without intersections of physical surfaces and neo-valve prolapse, and the position of the suture boundary satisfies the boundary conditions. To solve this problem, we tried to mimic neocusps suturing in Ozaki’s operation. As a result, we propose a new algorithm for ‘virtual suturing’ of given neocusps, considered as thin shells. The approach is able to work with both small and large (compared to an optimal size) neocusps and to handle each cusp independently of the others.

Understanding aortic valve repair through Ozaki procedure: A review of literature evidence.

Aortic valve neocuspidization (AV Neo) using glutaraldehyde-treated autologous pericardium was first reported by Ozaki et al. in 2007. This technique has become an alternative to tissue and mechanical valve in selected patients as long-term anticoagulation is not required and shows promising midterm results and durability. A comprehensive search was performed on the major database using the search terms "Ozaki technique" AND "Aortic Valve Neocuspidization" AND "AV Neocuspidization" AND "Autologous pericardium" AND "glutaraldehyde-treated autologous pericardium."Articles up to August 1st, 2021 were included in this study. A total of nine studies with a total of 1342 patients were included. The mean age was 67.36 and 54.23% were male. 66.32% and 23.92% of patients had aortic stenosis and aortic regurgitation, respectively. 66% of patients had a native tricuspid aortic valve (AV) and 31.37% ofpatients' native AV was bicuspid. Three studies reported their experience performing AV Neo via ministernotomy. AV Neo can be a suitable alternative to surgical AV replacement in selected patients. The short- and midterm outcomes are comparable without the need for long-term oral anticoagulation. Long-term follow-up data are required for this novel approach to be widely adopted.

Aortic valve neocuspidization using autologous versus bovine pericardium: Ozaki versus Batista.

The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients' quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimizing foreign valve tissue. AV Neo can either be performed using glutaraldehyde-treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes, and limitations of the Ozaki procedure, and compare this to the Batista procedure. A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase, and Scopus to collate the relevant research evidence. Although the Ozaki procedure can achieve favorable results whilst mainly avoiding the need for life-long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde-treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki's, including excellent survival, lower complications, and minimal need for reoperation as well as shorter operative times. AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure.

AVNeo improves early haemodynamics in regurgitant bicuspid aortic valves compared to aortic valve repair.

Calcified or fibrotic cusps in patients with bicuspid aortic valves and aortic regurgitation complicate successful aortic valve (AV)-repair. Aortic valve neocuspidization (AVNeo) with autologous pericardium offers an alternative treatment to prosthetic valve replacement. We compared patients with regurgitant bicuspid valves undergoing AV-repair or AVNeo. We retrospectively analysed patients with regurgitant bicuspid valves undergoing AV-repair or AVNeo. We focused on residual regurgitation, pressure gradients and effective orifice area, determined preoperatively and at discharge. AV-repair was performed in 61 patients (mean age: 43.2 ± 11.3 years) and AVNeo in 22 (45.7 ± 14.1). Prior to the operation patients of the AV-repair group showed severe regurgitation in 38 cases (62.3%) and moderate in 23 (37.6%); in the AVNeo group, all patients exhibited severe regurgitation. Postoperatively, 57 patients (93.4%) patients had no or mild regurgitation after AV-repair and 21 (95.4%) after AVNeo. In AVNeo-patients, peak (10.6 ± 3.1 mmHg vs 22.7 ± 11 mmHg, P&lt; 0.001) and mean pressure gradients (5.9 ± 2 mmHg vs 13.8 ± 7.3 mmHg, P &lt; 0.001) were significantly lower and the orifice area significantly larger (2.9 ± 0.8 cm2 vs 1.9 ± 0.7 cm2, P &lt; 0.001) compared to repair. Compared to AV-repair, patients AVNeo showed lower mean pressure gradients and larger orifice areas at discharge. The functional result was not different.

Aortic valve neocuspidization using autologous pericardium compared to surgical aortic valve replacement.

Aortic valve neocuspidization (AVNeo) for trileaflet aortic valve reconstruction using autologous pericardium (Ozaki procedure) depicts an encouraging new technique for the surgical treatment of aortic valve pathologies. The current study analyzes the early hemodynamic outcome of AVneo compared with surgical aortic valve replacement (SAVR) using the Abbott/St. Jude Trifecta aortic valve biological prostheses. All patients who underwent either AVNeo or SAVR between March 2017 and April 2020 were included. Exclusion criteria were emergency cases, endocarditis, redo- or additional root procedures. Main endpoints were differences between the two groups in terms of the effective orifice area (EOA) and the effective orifice area index (EOAI) at discharge. During the study period, 105 AVNeo patients and 458 SAVR patients met the inclusion criteria. EOA was significantly higher in the AVNeo group (2.4 cm2 ± 0.8 vs. 2.1 cm2 /m2 ± 0.6 in the SAVR group, respectively; p < .001). Multiple regression analysis, including AVNeo, annulus size, bicuspid valve, preoperative stenosis, left ventricular ejection fraction (LVEF), and diastolic diameter (LVEDD) found two factors, which favor larger EOA: Annulus size (p < .0001) and AVneo (p = .005). EOAI was significantly higher in the AVNeo group (1.23 ± 0.4 vs. 1.02 cm2 /m2 ± 0.3, respectively; p < .001). Multiple regression analysis for EOAI showed effects for AVneo (p = .005) and bicuspid valve (p = .029). Mean pressure gradients (MPG) were lower in the AVNeo group than in the SAVR group (AVNeo: MPG = 8.0 mmHg ± 3.6 vs. SAVR: MPG = 8.3 mmHg ± 3.6), but this finding did not reach statistical significance (p = .091). AVNeo shows significantly larger EOA and EOAI compared to SAVR using the Abbott/St. Jude Trifecta aortic valve biological prostheses.

Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium to avoid the prosthesis-patient mismatch of a severely obese 57-year-old patient—a case report

Video 1 Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium in a severely obese non-elderly patient: a way to avoid the prosthesis-patient mismatch.

Aortic valve neocuspidization: Frequently asked technical questions.

Since the first description by Professor Ozaki in 2011, more than 5500 aortic valve neocuspidization procedures have been performed worldwide, with promising short- and mid-term outcomes. We here report the nuances required to master this highly reproducible, standardized technique for the treatment of aortic valve disease.

Aortic valve neocuspidization and its technical nuance.

Aortic valve neocuspidization or Ozaki procedure represents an advanced surgical strategy for the management of patients with aortic valvulopathy. It has been shown to have clinical and hemodynamic outcomes that compare favorably with aortic valve replacement as it restores physiological aortic valve function and left ventricular remodeling. There are, however, a new set of issues including structural valve deterioration, leaflet tear/perforation, and need for reoperation. A keen understanding of the technical nuances involved with the Ozaki procedure may help in reducing the incidence of such adverse outcomes.

Corrigendum to: 1292 Aortic Valve Neocuspidization Using Glutaraldehyde-Treated Autologous Pericardium: A Literature Review.

Corrigendum to: 1292 Aortic Valve Neocuspidization Using Glutaraldehyde-Treated Autologous Pericardium: A Literature Review.

Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization

BackgroundAortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo.MethodsData-available consecutive 38 patients (median age, 77; interquartile range, 72.8–82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling.ResultsThe Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling.ConclusionsLow global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.

Management of intraoperative transesophageal echocardiography in aortic valve neocuspidization (Ozaki procedure)

Management of intraoperative transesophageal echocardiography in aortic valve neocuspidization (Ozaki procedure)

Risk of infective endocarditis after aortic valve neocuspidization (Ozaki procedure): a multiple-center study

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценка частоты и определение факторов риска инфекционного эндокардита (ИЭ) после неокуспидализации аортального клапана. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В исследование был включен 251 пациент (116 мужчин и 135 женщин) с патологией аортального клапана, которым выполняли неокуспидализацию аортального клапана в период с 2016 по 2019 г. в четырех российских центрах. Медиана периода наблюдения составила 24 [17; 32] мес. <h3>РЕЗУЛЬТАТЫ</h3> ИЭ после операции развился у 7 (2,8%) пациентов. По результатам построения кривых Каплана—Мейера ИЭ отсутствовал после неокуспидализации аортального клапана в течение 3 лет в 96,6% случаев, повторные операции в течение 3 лет отсутствовали в 94,6% случаев, а 3-летняя общая выживаемость составила 90,6%. Факторы риска ИЭ включали операцию по поводу активного ИЭ (относительный риск 16,5; 95% ДИ 2,85—95,54; <i>p</i>=0,002) и ишемическую болезнь сердца с чрескожным коронарным вмешательством в анамнезе (относительный риск 11,6; 95% ДИ 2,24—60,14; <i>p</i>=0,003). <h3>ВЫВОД</h3> Потенциально операция неокуспидализации аортального клапана может снизить количество инфекционных осложнений в определенных группах больных. Необходимы дальнейшие проспективные многоцентровые исследования для подтверждения данной гипотезы.

Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium in a severely obese non-elderly patient: a way to avoid the prosthesis-patient mismatch.

Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium in a severely obese non-elderly patient: a way to avoid the prosthesis-patient mismatch.