Comparison of the results of aortic valve neocuspidalization (Ozaki procedure) with aortic valve bioprosthetics in patients with a narrow aortic annulus: a multicenter retrospective study

In aortic valve (AV) replacement surgery in patients with a narrow annulus fibrosus (AF), the likelihood of prosthesis-patient mismatch (PPM) is high. PPM, in turn, significantly affects the hemodynamic and functional capabilities of AV, morbidity and mortality in the postoperative period. The “gold standard” for the treatment of AV diseases is prosthetics with mechanical and biological prostheses. However, there are alternative methods, such as neocuspidalization of AV according to the S. Ozaki (AVNeo) method.

Aim: To compare the immediate and medium-term results of AV prosthetics using the S. Ozaki (AVNeo) technique and AV prosthetics with a biological prosthesis in patients with a small aortic annulus.

Material and Methods: A retrospective multicenter study of 309 patients with a narrow fibrous ring of the aortic valve (FR AV) who underwent surgery between February 2010 and December 2021 was conducted. Inclusion criteria: prosthetics of AV, FR AV = 21 mm, age 18 years and older. Exclusion criteria: left ventricle ejection fraction ≤ 40%, repeated interventions, mini-stop. 153 patients underwent Aveo and 156 patients underwent AV prosthetics using biological prostheses. After “pseudorandomization” (propensity score matching), 92 patients were selected: 46 patients in the AVNeo group and 46 patients in the biological prosthesis group. The primary endpoint was hospital mortality. Postoperative complications, transvalvular gradients, and medium-term outcomes (three-year overall survival and freedom from surgery on AV) were evaluated as secondary endpoints.

Results. There was no statistically significant difference in the duration of surgery (275.9 ± 34.2 min in the AVNeo group and 285.8 ± 37 min in the bioprosthesis group, p < 0.4), artificial circulation (98 min in the AVNeo group and 115 min in the bioprosthesis group, p < 0.3), aortic compression (80 min in the AVNeo group and 93 min in the bioprosthesis group, p < 0.7). Hospital mortality among the studied patients did not differ: in the AVNeo group – 2 (4.3%) and 1 (2.2%) in the bioprosthesis group, p = 1.0. There were no significant differences in postoperative complications: wound surface infection (3 (6.5%) in the AVNeo group and 1 (2.2%) in the bioprosthesis group, p = 0.617), acute kidney injury (1 (2.2%) in the AVNeo group and 0 in the bioprosthesis group, p = 1.0), stroke ( 1 (2.2%) in the AVNeo group and 2 (4.3%) in the bioprosthesis group, p = 1.0), resternotomy for bleeding (0 in the AVNeo group and 2 (4.3%) in the bioprosthesis group, p = 0.495). Permanent pacemaker implantation was not required by any patient. There was also no statistically significant difference in the three-year overall survival and re–operation, in the AVNeo group it was 83% and 92.5% in the bioprosthesis group, p = 0.23; three-year freedom from re-operation was 96.4% in the AVNeo group and 97.1% in the bioprosthesis group, p = 0.27. However, peak and average gradients were statistically less after AVNeo surgery. The peak and average gradients after AVNeo were 12 and 6 mmHg, after prosthetics 32 and 20 mmHg, p < 0.001.

Conclusions: There was no statistically significant difference in hospital mortality, postoperative complications, and three-year survival and re-operation. The values of the peak and average pressure gradient at discharge differed statistically significantly in favor of the AVNeo group.

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