WJCSWorld Journal of Cardiovascular Surgery2164-3202Scientific Research Publishing10.4236/wjcs.2021.116008WJCS-111687ArticlesMedicine&Healthcare Aortic Neocuspidization with Autologous Pericardium: Initial Experience of Single Center KubilayKarabacak1*EmreKubat1GökhanErol1MuratKadan1FurkanBurak Akyol1ElginHacızade1SuatDoganci1MehmetEmin Ince2UygarCagdas Yuksel3MuratCelik3CengizBolcal1Department of Cardiovascular Surgery, Gülhane School of Medicine, Health Sciences University, Ankara, TurkeyDepartment of Cardiology, Gülhane School of Medicine, Health Sciences University, Ankara, TurkeyDepartment of Anesthesiology, Gülhane School of Medicine, Health Sciences University, Ankara, Turkey30062021110651602, June 202127, June 2021 30, June, 2021© Copyright 2014 by authors and Scientific Research Publishing Inc. 2014This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

Background: Aortic neo-cuspidization (AVNeo) procedure has been adopted by limited centers with the publication of the mid-long term successful results. The aim of this study was to present initial experience of the AVNeo procedure of a single center. Methods: The medical records of 24 patients who underwent AVNeo with or without concomitant cardiac surgery between February 2019 and February 2021 at our tertiary hospital were scanned retrospectively. Results: The mean age of patients was aged 58.21 ± 13.14 years and 16 (66.7%) of them were men. 16 patients were operated on for aortic steno sis (66.67%). Morphology of the aortic valve was tricuspid in 21 (87.5%) and bicuspid in 3 (12.5%) of the patients. Additional cardicac surgery was performed in 13 (54.17%) patients. No patients needed reoperation for bleeding, pacemaker implantations, conversion to classical prosthetic aortic valve replacement , or infective endocarditis. Two patients died due to non-cardiac reasons . Preoperative peak and mean aortic valve pressures improved significantly at 1st and 6th months (Preop: 89.06 ± 21.88 mmHg and 56.38 ± 15.09 mmHg 1st month: 22.00 ± 3.93 mmHg and 8.73 ± 2.60 mmHg, 6th month: 18.13 ± 3.02 mmHg and 6.93 ± 1.83 mmHg) . Conclusion: In conclusion, the AVNeo procedure is a feasible technique for aortic valve pathologies, with the advantages of avoiding anticoagulants and the applicability of concomitant surgical procedures. Although this procedure requires meticulous experience, results similar to the available published literature can be obtained and reproducible even during learning curve when technical steps are strictly followed.

Ozaki Procedure Aortic Valve Repair Autologous Pericardium1. Introduction

Aortic valve replacement (AVR) with mechanical or bioprosthetic valves is still a standart approach for aortic valve diseases. Despite the durability, due to the need for long-term anticoagulation, morbidity and mortality such as bleeding and thromboembolic events reduce the desire of surgeons to use mechanical valves. For aortic valve disease, bioprosthetic valves are increasingly being used in elderly patients for replacement. However, despite advances in the design and construction of prosthetic valves, hemodynamic performance cannot yet be compared to that of natural aortic valves. Aortic valve repair is performed infrequently only by some experienced centers for only a selected group of aortic valve disease patients due to technical difficulties and durability of applied techniques. Thus, aortic valve neocuspidization (AVNeo) has emerged as another option that can be applied to a wide spectrum of aortic pathologies. Aortic valve reconstruction with a glutaraldehyde-treated autologous pericardium in patients with aortic valve disease was proposed and started by Duran et al. in 1995 [1]. Since then, different techniques have been reported. In 2011, Ozaki et al. published their first case series of aortic valve neocuspidisation for aortic valve disease with glutaraldehyde-treated autologous pericardium in 88 patients between April 2007 and August 2009 [2]. One of the main advantages of this method, the natural aortic root expansion in systole with maximal effective orifice area was achieved when compared with aortic valve replacement. AVNeo procedure has been adopted by limited centers with the publication of the mid-long term successful results. In our department, we started performing the Ozaki procedure for patients with aortic valve disease in February 2019. The aim of our study was to present short and mid-term results of the Ozaki procedure.

2. Methods2.1. Study Design

24 patients who underwent AVNeo with or without concomitant cardiac surgery between February 2019 and February 2021 in the cardiac surgery department of our university hospital were included in this study. Patient’s medical records were prospectively gathered and retrospectively analyzed from the electronic database of our hospital. The study protocol was approved by the local ethics committee (date: January 28, 2021; no. 2021/45). The study was conducted in accordance with the principles of the Declaration of Helsinki. In the current study, patients’ preoperative clinical features, operative data (including aortic cusps sizes) and postoperative echocardiographic results were recorded.

2.2. Surgical Technique

This technique is routinely performed with median sternotomy incision with standardized aorto-caval/bicaval cannulation. Briefly, pericardial patches should be taken with care and treated with glutaraldehyde solutions. After resection of aortic cusps, the new pericardial aortic cusps are sewn into aortic annulus according to measurement of each aortic cusp. This sizing is crucial for procedural success. After sewing these three cusps, aortotomy incision was closed as usual, and the operation was completed with standardized techniques. Surgical steps of this technique for cuspis preparation and implantation have been explained in detail in previous articles [2] [3] [4] [5] [6].

2.3. Statistics

Statistical analysis was performed using the SPSS for Windows version 15.0 (SPSS Inc., Chicago, IL, USA). Continuous variables are expressed as mean ± standard deviation (SD) and categorical variables as numbers (n) and percentages (%). Friedman tests were conducted to test whether there is a significant change in the peak and mean aortic valve pressure, due to violations of parametric test assumptions (non-normal distribution and low number of cases). The Wilcoxon tests were performed to test the significance of pairwise differences using Bonferroni correction to adjust for multiple comparisons.

3. Results3.1. Preoperative Characteristics

The mean age of patients was 58.21 ± 13.14 (min - max: 24 - 79) years and 16 (66.7%) of them were male. The mean body surface area of the patients was 28.3 ± 3.7 kg/m2. The distribution of the comorbidities was as follows: Coronary artery disease in 3 (12.5%), hypertension in 5 (20.8%), diabetes in 8 (33.3%) and COPD in 4 (16.7%) of the patients. Preoperative characteristics of each patient are listed in Table 1. Preoperative echocardiographic measurements of the patients revealed the mean left ventricular ejection fraction of 59% ± 7.2% and mean aortic annulus diameter of 23.1 ± 2.8 mm. 13 (54.17%) patients needed concomitant cardiac procedures. 16 (66.67%) patients presented with aortic stenosis (AS). Preoperative echocardiography showed an average peak and mean aortic valve pressures as 89.06 ± 21.88 mmHg and 56.38 ± 15.09 mmHg, respectively. Morphology of the aortic valve was tricuspid in 21 (87.5%) and bicuspid was in 3 (12.5%) of the patients. The mean Society of Thoracic Surgeons score and logistic Euroscore were 1.16 ± 1 (0.33 - 3.92) and 4.41 ± 4.92 (0.46 - 17.05), respectively.

3.2. Operative Data

Patient’s operative data and aortic cusps sizes were presented in Table 1. Concomitant procedures included 5 mitral valve replacements, 1 mitral valve repair, 3 coronary artery bypass surgeries, 3 ascending aortic replacements, 1 left atrial appendage internal plication and 1 pulmonary valve replacement operation. Aortic cups sizes were presented in Table 1. Mean aortic cross-clamping (ACC) time was 118.1 ± 33.2 (min - max: 67 - 173) minutes and total cardiopulmoner bypass (CPB) time was 162 ± 45.7 (min - max: 97 - 245) minutes. For isolated aortic valve pathologies, mean ACC time and CPB time were 93.3 ± 18.2 (min - max:

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