Comparison of immediate results of Ozaki neocuspidization and mechanical prosthesis implantation in patients with bicuspid aortic valve and ascending aorta dilatation

Introduction. Modern advances in bicuspid aortic valve (BAV) reconstructive surgery, despite their significance, have significant limitations. Neocuspidization using autologous pericardium (Ozaki technique) is considered as an alternative approach to correcting BAV pathology. Up to 50% of patients with BAV have associated aortopathy, which can involve the proximal aorta and mid-portion of the ascending aorta. In this article, we present a comparative analysis of the results of Ozaki neocuspidation and mechanical prosthesis implantation in patients with bicuspid aortic valves and concomitant ascending aortic valve replacement (AVR).

Aim: To compare the immediate outcomes of Ozaki neocuspidization and mechanical prosthesis implantation in patients with bicuspid aortic valves and concomitant ascending aortic valve replacement.

Material and Methods. The study included 137 patients who underwent surgery at the clinic between January 2017 and January 2025. A retrospective observational comparison of surgical outcomes of two groups was performed: Group 1 – the study group, consisting of 63 patients who underwent neocuspidization using the Ozaki technique combined with ascending aortic replacement; Group 2 – the control group, consisting of 74 participants who underwent AVR with a mechanical prosthesis and ascending aortic replacement.

Results. A statistically significant difference was observed based on postoperative ultrasound data: the effective orifice area in Group 1 was 4.7 ± 1.1 versus 2.3 ± 0.4 in Group 2 (p = 0.04). The mean gradient was 4.5 ± 2.1 in Group 1 and 10.6 ± 2.2 in Group 2 (p = 0.04). The maximum gradient was 9.5 ± 2.8 and 17.6 ± 2.9 in Groups 1 and 2, respectively (p = 0.04). In-hospital mortality and the incidence of postoperative complications did not differ significantly between the two groups.

Conclusion. No statistically significant differences were observed in in-hospital comparisons of intraoperative characteristics and early postoperative complications. However, significantly better hemodynamic parameters were observed in the study group.

1. Ehrlich T., de Kerchove L., Vojacek J., et al. State-of-the art bicuspid aortic valve repair in 2020. Prog. Cardiovasc. Dis. 2020;63(4):457–464. DOI: 10.1016/j.pcad.2020.04.010

2. Karaskov A.M., Chernyavskiy A.M., Porkhanov V.A., et al. Reconstructive surgery of the aortic root. Novosibirsk: Geo; 2006:255. (In Russ.). ISBN: 5-9747-0024-4

3. Lansakara M., Unai S., Ozaki S. Ozaki procedure-re-construction of aortic valve leaflets using autologous pericardial tissue: a review. Indian J. Thorac. Cardiovasc. Surg. 2023;39(Suppl 2):260–269. DOI: 10.1007/s12055-023-01635-z

4. Ziganshin B.A., Elefteriades J.A. Guilt by association: a paradigm for detection of silent aortic disease. Ann. Cardiothorac. Surg. 2016;5(3):174–87. DOI: 10.21037/acs.2016.05.13

5. Biner S., Rafique A.M., Ray I., et al. Aortopathy is prevalent in relatives of bicuspid aortic valve patients. J. Am. Coll. Cardiol. 2009;53:2288–2295. DOI: 10.1016/j.jacc.2009.03.027

6. Lang R.M., Bierig M., Devereux R.B., et al. American Society of Echocardiography's Nomenclature and Standards Committee; Task Force on Chamber Quantification; American College of Cardiology Echocardiography Committee; American Heart Association; European Association of Echocardiography, European Society of Cardiology. Recommendations for chamber quantification. Eur. J. Echocardiogr. 2006;7(2):79–108. DOI: 10.1016/j.euje.2005.12.014

7. Sievers H.H., Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J. Thorac. Cardiovasc. Surg. 2007;133(5):1226–1233. DOI: 10.1016/j.jtcvs.2007.01.039

8. Clinical guidelines. Aneurysms of the thoracic and thoracoabdominal aorta. Cardiology and Cardiovascular Surgery. 2025;18(4):493–567. (In Russ.). DOI: 10.17116/kardio202518041493 EDN: GJLSDH

9. Gavrilenkov V.I., Khubulava G.G., Pavlov M.V. Bicuspid aortopathy: classification, technique and immediate results of interventions on the aortic valve and proximal aorta. Russian Journal of Thoracic and Cardiovascular Surgery. 2024;66(1):43–54. (In Russ.). DOI: 10.24022/0236-2791-2024-66-1-43-54 EDN: CGBRAT

10. Bazylev V.V., Rosseykin E.V., Babukov R.M., Mikulyak A.I., Bartosh F.L., Slastin Ya.S. Comparison of early and mid-term results in patients with a narrow aortic root after aortic valve replacement with a biological prosthesis with annulo-enlarging plasty of the aortic root and aortic leaflet replacement with autopericardium using the S. Ozaki technique. Clinical and Experimental Surgery. Petrovsky Journal. 2019;7(1):34–43. (In Russ.). DOI: 10.24411/2308-1198-2019-11005 EDN: CQGSRQ

11. Koechlin L., Eckstein F. S. Aortic Valve Neocuspidization Using Autologous Pericardium (Ozaki Procedure): an Alternative to Aortic Valve Replacement in Adult Cardiac Surgery? Current Anesthesiology Reports. 2021;11(3):318–325. DOI: 10.1007/s40140-021-00454-5

12. Kadyraliev B.K., Belov V.A., Marchenko A.V., et al. Comparison of outcomes of aortic valve neocuspidalization (Ozaki procedure) versus aortic valve bioprosthesis in patients with a narrow fibrous ring: a multicenter retrospective study. Siberian Journal of Clinical and Experimental Medicine. 2024;39(4):56–65. (In Russ.). DOI: 10.29001/2073-8552-2024-39-4-56-65 EDN: IPSXJU

13. Rosseykin E.V., Kobzev E.E., Skidan V.I., Potopalsky I.D. Ozaki procedure in a patient with severe aortic stenosis and extremely low left ventricular ejection fraction. Siberian Journal of Clinical and Experimental Medicine. 2021;36(1):129–133. (In Russ.). DOI: 10.29001/2073-8552-2021-36-1-129-133 EDN: HPCFBR

14. Kozlov B.N., Panfilov D.S., Bazarbekova B.A., Panfilova N.O. Comparative analysis of changes in Valsalva sinus dimensions in the mid-term follow-up after replacement of the ascending aorta and bicuspid/ tricuspid aortic valve. Siberian Journal of Clinical and Experimental Medicine. 2025;40(2):53–61. (In Russ.). DOI: 10.29001/2073-8552-2025-40-2-53-61 EDN: BKUPAW

15. Vendramin I., Meneguzzi M., Sponga S., et al. Bicuspid aortic valve disease and ascending aortic aneurysm: should an aortic root replacement be mandatory? Eur. J. Cardiothorac. Surg. 2016;49(1):103–109. DOI: 10.1093/ejcts/ezv069

16. Bibevski S., Ruzmetov M., Plate J.F., Scholl F.G. The impact of bicuspid aortic valve leaflet fusion morphology on the ascending aorta and on outcomes of aortic valve replacement. Tex. Heart Inst. J. 2023;50(2):e217831. DOI: 10.14503/THIJ-21-7831

17. Unai S., Ozaki S., Johnston D.R., et al. Aortic Valve Reconstruction With Autologous Pericardium Versus a Bioprosthesis: The Ozaki Procedure in Perspective. J. Am. Heart Assoc. 2023;12(2):e027391. DOI: 10.1161/JAHA.122.027391

18. Zhang C., Butt S., Kashif H., et al. Aortic Valve Replacement and Repair With or Without Concomitant Ascending Aorta Replacement: Impact on Outcomes: A Systematic Review. Cardiol. Rev. 2025;33(5):407–418. DOI:10.1097/CRD.0000000000000623