CONGENITAL – Original Submission| Volume 34, ISSUE 4, P1262-1272, December 2022

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

Published:October 28, 2021DOI:
      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.

      Graphical Abstract



      AR (aortic regurgitation), AS (aortic stenosis), AVNeo (aortic valve neo-cuspidization), BSA (body surface area), CPB (cardiopulmonary bypass), ICU (intensive care unit), JOMDD (Japanese Organization for Medical Device Development, Inc.), LOS (length of stay), LVEDV (left ventricular end-diastolic volume), LVEDVz (Z score of left ventricular end-diastolic volume), RV (right ventricle), PA (pulmonary artery)
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        • Boodhwani M.
        • El Khoury G.
        Aortic valve repair.
        Oper Tech Thorac Cardiovasc Surg. 2009; 14: 266-280
        • Baird C.W.
        • Cooney B.
        • Chávez M.
        • et al.
        Congenital aortic and truncal valve reconstruction using the Ozaki technique: Short-term clinical results.
        J Thorac Cardiovasc Surg. 2021; 161: 1567-1577
        • Myers P.O.
        • Mokashi S.A.
        • Horgan E.
        • 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
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • et al.
        Aortic valve reconstruction using self-developed aortic valve plasty system in aortic valve disease.
        Interact Cardiovasc Thorac Surg. 2011; 12: 550-553
        • Ozaki S.
        • Kawase I.
        • Yamashita H.
        • 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.
        • 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.
        • et al.
        Aortic valve reconstruction using autologous pericardium for aortic stenosis.
        Circ J. 2015; 79: 1504-1510
        • Baird C.W.
        • Marathe S.P.
        • del Nido P.J.
        Aortic valve neo-cuspidation using the Ozaki technique for acquired and congenital disease: where does this procedure currently stand?.
        Indian J Thorac Cardiovasc Surg. 2020; 36: 113-122
        • Marathe S.P.
        • Chávez M.
        • Sleeper L.A.
        • et al.
        Modified Ozaki procedure including annular enlargement for small aortic annuli in young patients.
        Ann Thorac Surg. 2020; 110: 1364-1371
        • Colan S.D.
        Normal echocardiographic values for cardiovascular structures.
        Echocardiography in Pediatric and Congenital Heart Disease. John Wiley & Sons, Ltd, 2016: 883-901
        • Vlahos A.P.
        • Marx G.R.
        • McElhinney D.
        • et al.
        Clinical utility of doppler echocardiography in assessing aortic stenosis severity and predicting need for intervention in children.
        Pediatr Cardiol. 2008; 29: 507-514
        • Schlingmann T.R.
        • Gauvreau K.
        • Colan S.D.
        • Powell A.J.
        Correction of doppler gradients for pressure recovery improves agreement with subsequent catheterization gradients in congenital aortic stenosis.
        J Am Soc Echocardiogr. 2015; 28: 1410-1417
        • Bacha E.A.
        • McElhinney D.B.
        • Guleserian K.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
        • Mazzitelli D.
        • Nöbauer C.
        • Rankin J.S.
        • et al.
        Complete aortic valve cusp replacement in the pediatric population using tissue-engineered Bovine pericardium.
        Ann Thorac Surg. 2015; 100: 1923-1925
        • Chivers S.C.
        • Pavy C.
        • Vaja R.
        • et al.
        The ozaki procedure with cardiocel patch for children and young adults with aortic valve disease: preliminary experience – a word of caution.
        World J Pediatr Congenit Hear Surg. 2019; 10: 724-730
        • Wiggins L.M.
        • Mimic B.
        • Issitt R.
        • et al.
        The utility of aortic valve leaflet reconstruction techniques in children and young adults.
        J Thorac Cardiovasc Surg. 2020; 159 (Epub 2019 Oct 26.): 2369-2378
        • Konstantinov I.E.
        • Naimo P.S.
        • Buratto E.
        Commentary: Ozaki valve reconstruction in children: Is it still a valve replacement?.
        J Thorac Cardiovasc Surg. 2021; 161 (Epub 2020 Feb 14): 1579-1581
        • Vida V.L.
        • Hoehn R.
        • Larrazabal L.A.
        • et al.
        Usefulness of intra-operative epicardial three-dimensional echocardiography to guide aortic valve repair in children.
        Am J Cardiol. 2009; 103: 852-856
        • Schäfers H.J.
        • Bierbach B.
        • Aicher D.
        A new approach to the assessment of aortic cusp geometry.
        J Thorac Cardiovasc Surg. 2006; 132: 436-438
        • Schäfers H.J.
        • Schmied W.
        • Marom G.
        • et al.
        Cusp height in aortic valves.
        J Thorac Cardiovasc Surg. 2013; 146: 269-274
        • Robicsek F.
        • Thubrikar M.J.
        • Cook J.W.
        • Fowler B.
        The congenitally bicuspid aortic valve: How does it function? Why does it fail?.
        Ann Thorac Surg. 2004; 77: 177-185
        • Konstantinov I.E.
        • D'Udekem Y.
        • Brizard C.P.
        Ross operation or aortic valve repair in neonates and infants?.
        J Thorac Cardiovasc Surg. 2014; 148: 362-363
        • Prêtre R.
        • Kadner A.
        • Dave H.
        • et al.
        Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves.
        Eur J Cardiothorac Surg. 2006; 29: 1001-1006
        • Aicher D.
        • Kunihara T.
        • Abou Issa O.
        • et al.
        Valve configuration determines long-term results after repair of the bicuspid aortic valve.
        Circulation. 2011; 123: 178-185
        • Kunihara T.
        • Aicher D.
        • Rodionycheva S.
        • et al.
        Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair.
        J Thorac Cardiovasc Surg. 2012; 143 (e1): 1389-1395
        • Taylor W.
        • Thrower W.
        • H B.
        • Harken D.E.
        The surgical correction of aortic insufficiency by Circumclusion.
        J Thorac Surg. 1958; 35: 192-205
        • David T.E.
        • Feindel C.M.
        An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.
        J Thorac Cardiovasc Surg. 1992; 103: 617-622
        • Lansac E.
        • Di Centa I.
        • Bonnet N.
        • et al.
        Aortic prosthetic ring annuloplasty: A useful adjunct to a standardized aortic valve-sparing procedure?.
        Eur J Cardiothorac Surg. 2006; 29: 537-544
        • Svensson L.G.
        Sizing for modified david's reimplantation procedure.
        Ann Thorac Surg. 2003; 76: 1751-1753
        • Schäfers H.J.
        Aortic annuloplasty: A new aspect of aortic valve repair.
        Eur J Cardiothorac Surg. 2012; 41: 1124-1125
        • Jawitz O.K.
        • Raman V.
        • Anand J.
        • et al.
        Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: early results from a single-centre experience.
        Eur J Cardiothorac Surg. 2020; 57: 1137-1144
        • Feins E.N.
        • Lee Y.
        • O'Cearbhaill E.D.
        • et al.
        A growth-accommodating implant for paediatric applications.
        Nat Biomed Eng. 2017; 1: 818-825

      Linked Article

      • Commentary: What is the Sound of One Hand Clapping?
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 4
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          Those fortunate enough to have heard Shigeyuki Ozaki describe the inception of his eponymous procedure will recall his frequent reference to “prayer hands” as an illustration of the intentional redundancy along the zone of coaptation that is created by using the (oversized) leaflet stencils. While speculative, some have suggested that this design may serve additionally to provide adjustment for annular growth or leaflet restriction while still maintaining valvar competence. In part because of this, Ozaki's experience in adults has engendered enthusiasm for extension of this technique to children, albeit with variable results and very modest follow-up.
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