Konstantinos S. Mylonas, MD a,#, Panagiotis T. Tasoudis, MS b,#, Dionysios Pavlopoulos, MD, PhD a, Meletios Kanakis, MD, PhD c, George T. Stavridis, MD, FETCS a, and Dimitrios V. Avgerinos, MD, PhD, FACS, FACC
Take Home Points:
- The midterm outcomes of the Ozaki procedure are excellent in terms of hemodynamics, survival, and freedom from reoperation.
Commentary from Dr. Shuhua Luo (Chengdu, Sichuan, China), section editor of Congenital
Cardiac Surgery Journal Watch:
- Summary:
A total of 22 studies reporting on 1,891 patients that underwent Ozaki reconstruction were included in this meta-analysis. 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). 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).
- Comment:
Ozaki’s procedure is a promising method to independently reconstruct the three leaflets of the aortic valve using autologous pericardium treated with glutaraldehyde. Most current data on this technique arise from single-center experiences, which are based on small patient populations. The present systematic review includes a total of 1,891 patients making it the largest and most comprehensive data synthesis to date on the Ozaki procedure. Although the results showed promising midterm outcomes of the Ozaki procedure, several questions remained to be answered in the future study.
(1) Aortic valve disease can be complicated at multiple levels such as left ventricular outflow tract obstruction(LVOT), aortic stenosis or regurgitation, aortic annulus stenosis or dilatation, and ascending aortic dilatation. In addition, many underlying causes can lead to aortic valve disease including infective endocarditis, rheumatic disease, or auto-immune pathologies. It is unknown whether the Ozaki procedure is a reasonable choice for these different clinical scenarios, as the current meta-analysis showed the majority of patients who underwent the Ozaki procedure had aortic stenosis, and the concomitant procedures such as LVOT muscle resection, aortic annular enlargement, or replacement of ascending aorta were not analyzed in the current study.
(2) The results of the Ozaki procedure in pediatric patients were particularly interesting. The mean age and body weight of pediatric patients was 12.3 ± 3.8 years and 42.1 ± 17.9 kg respectively, indicating that the size of patients was near to adult when undergoing Ozaki procedure. The aortic valve disease in young infants or small children posed a significant clinical challenge as the machinal prosthesis replacement was not usually an option due to the small size of the aortic annulus, and the Ross procedure was associated with high mortality. It will be interesting to look at the outcome of the Ozaki procedure in young children.
(3) Although the original Ozaki procedure included the tricuspid leaflets reconstruction, some patients only need a single-cusp reconstruction using the Ozaki principle. It remains to know that the percentage of patients who only received a single-cusp reconstruction in the current meta-analysis, may have the potential impact on the midterm outcome.
In summary, the Ozaki procedure is an attractive alternative for aortic valve disease in patients. We are looking forward to more data shed light on the surgical decision-making in various clinical scenarios, including patients’ size, individual detailed anatomy, and underlying causes.
