Aortic Valve Neocuspidization (Ozaki Procedure) in Patients with Small Aortic Annulus (≤21 mm): A Multicenter Study

Background Patients with aortic stenosis (AS) and small aortic annulus (SAA) who undergo surgical aortic valve replacement (SAVR) are more likely to receive smaller prostheses, predisposing them to prosthesis patient-mismatch (PPM). Since the Ozaki Procedure (aortic valve neocuspidization – AVNeo) has proved promising, we aimed to assess its immediate results in this scenario. Methods AVNeo was performed in 106 consecutive patients from January 2017 to March 2019 at three centers. The records were prospectively collected and reviewed retrospectively. Most of the patients were older than 60 years and 97.2% had AS. Preoperative echocardiography showed an average peak pressure gradient of 64.9 ± 20.7 mmHg and a mean pressure gradient of 46.0 ± 12.2 mm Hg for patients with AS and an annular diameter of 19.8 ± 1.1 mm for all patients. EOA and indexed EOA (iEOA) averaged 0.7 ± 0.2 cm 2 and 0.4 ± 0.2 cm 2 /m 2 before surgery, respectively. Results There was no conversion to SAVR. Four patients needed reoperation for bleeding, but none needed reoperation due to early infective endocarditis. Median intensive care unit and hospital length of stay were 1.5 ± 1.2 and 13.7 ± 5.1 days, respectively. There were two in-hospital deaths due to non-cardiac causes. Postoperative peak pressure gradient averaged 11.8 ± 5.9 mmHg and mean pressure gradient averaged 7.3 ± 3.5 mmHg, which means statistically significant average decreases of 58.1 and 38.7 mmHg, respectively. Postoperative EOA and iEOA averaged 2.5 ± 0.4 cm 2 and 1.3 ± 0.3 cm 2 /m 2 , which means statistically significant average increases of 1.8 cm 2 and 0.9 cm 2 /m 2 , respectively. Conclusions AVNeo is feasible and reproducible with good immediate results. Our findings show that AVNeo produces immediate postoperative low-pressure gradients, larger EOA, and minimal regurgitation of the aortic valve.