Midterm results of Ozaki technique for aortic valve reconstruction comparing autologous and bovine pericardium in congenital aortic valve disease

Objective: Aortic valve reconstruction (AVNeo) with neocuspidization, or the Ozaki procedure with complete cusp replacement for aortic valve disease, has excellent immediate-term technical results in children and midterm results in adults. Limited midterm results of AVNeo in younger patients have been reported. We report our midterm outcomes of neocuspidization with Ozaki technique for congenital aortic and truncal valve disease. Methods: A retrospective analysis was performed on all patients with congenital aortic and truncal valve disease who had a 3-leaflet AVNeo procedure at a single institution from August 2015 to June 2023. Outcome measures included mortality, surgical or catheter-based reinterventions, and echocardiography. Results: In total, 74 patients aged 12.8 ± 7.3 years underwent 3 leaflet AVNeo; 31 patients had aortic regurgitation (AR), 7 had aortic stenosis (AS), and 36 patients had AS/AR. Five patients had truncus arteriosus. The aortic valve was quadricuspid in 2.7%, 46% tricuspid, 34% bicuspid, and 18% unicusp of patients. In total, 57% had previous aortic valve repairs and 9% had replacements. Preoperative echocardiography mean annular diameter was 2.03 ± 0.48 cm, and peak gradient for patients with AS/AR was 60.1 ± 24.4 mm Hg. Autologous pericardium was used in 42% (n = 31) of patients, PhotoFix bovine in 58% (n = 43) of patients, and CardioCel bovine pericardium in 2% (n = 2) of patients. In total, 71 patients had concomitant procedures, including 11 who underwent aortic root enlargement including 34 with aortic sinus enlargement. Median intensive care unit and hospital length of stay were 1.9 and 7.0 days, respectively. There were no hospital mortalities or early conversions to valve replacement. At discharge, 95% of patients had mild or less regurgitation and median peak aortic gradient was 16.9 ± 9.0 mm Hg. Over median follow-up of 3.2 years, 30 patients (40%) required aortic valve reoperation (PhotoFix, 25/43 patients, 58%; and autologous, 5/31 patients, 16%). Freedom from reoperation at 1 and 3 years for autologous was 97 and 86%, and for PhotoFix was 97% and 75% (P = .006). Freedom from a composite outcome of moderate or greater regurgitation and/or reoperation at 1 and 3 years for autologous was 89% and 67% and for PhotoFix was 92% and 54% (P = .13). Failure mode for autologous pericardium was related to calcification and for PhotoFix pericardium was dehiscence at the annular suture line. Conclusions: The AVNeo procedure has acceptable short-term results in all patients but especially poor midterm results with PhotoFix bovine pericardium. AVNeo could be considered with caution for valve reconstruction in congenital patients if native autologous pericardium is available.