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S. Ozaki, I. Kawase, Hiromasa Yamashita, S. Uchida, Mikio Takatoh, N. Kiyohara (2018)
Midterm outcomes after aortic valve neocuspidization with glutaraldehyde‐treated autologous pericardiumThe Journal of Thoracic and Cardiovascular Surgery, 155
Ozaki (2018)
2379J Thorac Cardiovasc Surg, 155
B. Bernhard, Joel Illi, M. Gloeckler, T. Pilgrim, F. Praz, S. Windecker, A. Haeberlin, C. Gräni (2022)
Imaging-Based, Patient-Specific Three-Dimensional Printing to Plan, Train, and Guide Cardiovascular Interventions: A Systematic Review and Meta-Analysis.Heart, lung & circulation
Bernhard (2022)
1203Heart Lung Circ, 31
Vijayan (2020)
186Indian J Thorac Cardiovasc Surg, 36
Shearn (2020)
1137JACC Case Rep, 2
Tsujimoto (2022)
1152Interact CardioVasc Thorac Surg, 34
J. Vijayan, Rakesh Lachma, Prasanna Rao, A. Bhat (2019)
Autologous pericardial aortic valve reconstruction: early results and comparison with mechanical valve replacementIndian Journal of Thoracic and Cardiovascular Surgery, 36
Takanori Tsujimoto, T. Tedoriya, K. Okada (2021)
Virtual reality-guided aortic valve leaflet reconstruction for type 0 bicuspid aortic stenosisInteractive Cardiovascular and Thoracic Surgery, 34
S. Pirola, G. Mastroiacovo, F. Arlati, G. Mostardini, A. Bonomi, Eleonora Penza, G. Polvani (2020)
Single Center Five Years' Experience of Ozaki Procedure: Midterm Follow-up.The Annals of thoracic surgery
S. Pirola, G. Mastroiacovo, G. Mostardini, A. Bonomi, M. Guglielmo, G. Muscogiuri, A. Baggiano, A. Montisci, G. Pontone, G. Polvani (2021)
Preoperative Ozaki technique measures on tridimensional engineered root.Journal of cardiovascular computed tomography
Pirola (2021)
1937Ann Thorac Surg, 111
A. Shearn, M. Ordoñez, F. Rapetto, M. Caputo, G. Biglino (2020)
Rapid Prototyping Flexible Aortic Models Aids Sizing of Valve Leaflets and Planning the Ozaki RepairJACC Case Reports, 2
Pirola (2022)
51J Cardiovasc Comput Tomogr, 16
The original Ozaki technique involves sizing and trimming the neovalve cusps during cross-clamp. It leads to prolongation of the ischaemic time, as compared to standard aortic valve replacement. We use preoperative computed tomography scanning of the patient’s aortic root to develop personalized templates for each leaflet. With this method, autopericardial implants are prepared before the initiation of the by- pass. It permits maximally adopting the procedure to the patient’s individual anatomy and to shorten the cross-clamp time. We present a case of a computed tomography-guided aortic valve neocuspidization and concomitant coronary artery bypass grafting with excellent short-term results. We discuss the feasibility and technical details of the novel technique. Keywords: Aortic stenosis � Aortic valve neocuspidization � Ozaki procedure � Personalized treatment mean gradient of 69 mmHg; moderate aortic insufficiency; AV INTRODUCTION orifice area 0.7 cm ; aortic annulus diameter 22 mm; pulmonary Aortic valve neocuspidization (AVNeo) is becoming increasingly artery pressure 45 mmHg; left ventricle ejection fraction 50%. popular as a method of aortic valve replacement (AVR). Excellent Coronary angiography revealed three-vessel coronary artery dis- short- and mid-term results are reported [1, 2]. An important dis- ease (left anterior descending; obtuse marginal 1; posterior advantage of the original AVNeo is the sizing and trimming of descending artery). The patient was qualified for surgical correc- the leaflets during cross-clamp, leading to prolongation of the tion: CT-guided AVNeo and coronary artery bypass grafting ischaemic time [3, 4]. Another drawback is that intercommissural (CABG). distances are measured on the collapsed aorta. This may lead to Our goal was to create a competent AVNeo valve entirely incorrect sizing [3]. based on preoperative CT measurements. An axial Over the last decades, cardiac computed tomography (CT) has electrocardiogram-gated cardiac CT (GE OPTIMA CT660) was become a valuable tool in guiding cardiovascular interventions performed. To develop a realistic three-dimensional (3D) model [5]. The next frontier is translating the patient’s preoperative of the patient’s AR data were exported to the 3D Slicer software imaging data into custom-made devices designed for managing (Version 4.11; http://www.slicer.org). The best AR image in dias- individual cases. tole was selected. It was segmented based on an adjustable We present a method to develop personalized AVNeo leaflets threshold. Only the voxels of interest (wall of the AR) were based on preoperative CT scanning of the patient’s aortic root marked. Raphe between left and right coronary cusps was used (AR). With this technique, leaflets are measured in diastole and as a guiding point for the commissure between the left and right prepared before the initiation of the bypass. We used it for the AVNeo leaflets. surgical management of a patient with severe aortic stenosis and The concept of the reconstruction was to achieve all three coronary artery disease. cusps of the AVNeo valve coapting under 120 . The geometric solution to this problem was found by localization of the Torricelli point (TP) within the triangle, with vertices in the cranial PATIENT AND METHODS points of the commissures (Fig. 1A). The length of the free edge A 71-year-old male was referred to us for symptomatic aortic of the cusp was calculated as the sum of the segments from the stenosis. Transthoracic echocardiography showed bicuspid aortic commissures to the TP. The height of the leaflet was determined valve (AV) type I (R-L) with a peak gradient of 105 mmHg, a from TP to the corresponding nadir. The coaptation zone (CZ) Presented at the 36th EACTS Annual Meeting, Milan, Italy, 6 October 2022. The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which per- mits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. ADULT CARDIAC 2 B. Todurov et al. / Interdisciplinary CardioVascular and Thoracic Surgery Figure 1: Development of the personalized AVNeo leaflets based on the preoperative 3D rendering of the patient’s aortic root. (A) Scheme of determining the length of the free margin of the patient-specific AVNeo leaflets. Localization of the Torricelli point (T) inside a triangle ABC, in which vertices are represented by the apexes of the commissures. The length of the free edge of the cusps is the sum of the segments from the vertices to the Torricelli point. Left coronary cusp = AT + BT; right coro- nary cusp = BT + CT; and non-coronary cusp = AT + CT. (B) Scheme to determine the height of the leaflet: cross-section of the AVNeo cusp through the plane of Torricelli and nadir points. Distance TD is the Coaptation Zone of the leaflet. Distance DN (solid line) multiplied by factor 1.1 is the belly part of the leaflet. Distance DN (dashed line) is the expected bulging of the leaflet after it is sutured down and distended under the blood pressure. (C) Personalized templates of computed to- mography-guided AVNeo leaflets. A: the apex of the commissure between the left and non-coronary cusps; AVNeo: aortic valve neocuspidization; B: the apex of the commissure between the left and right coronary cusps; C: the apex of the commissure between the right and non-coronary cusps; D: caudal point of the coaptation zone; LCA: left coronary artery; N: the nadir; RCA: right coronary artery. was designed to start at the horizontal plane of the commissures 3 mm to allow plication while suturing. Plastic templates of each (Fig. 1B). The height of the CZ was set to be 8 mm. The distance cusp were prepared and sterilized (Fig. 1C). from the caudal point of the CZ to the nadir was calculated using 3D Modelling Software and multiplied by factor 1.1 to permit fu- SURGICAL TECHNIQUE ture bulging. Adding to this number the height of the CZ resulted in the total height of the leaflet. The length and the configuration After midline sternotomy, an 8 cm 9 cm piece of glutaraldehyde- of the aortic annulus determined the length and the configura- treated autopericardium was prepared as a standard for the Ozaki tion of the sewing margin of the respective leaflet. Based on these procedure [1]. Leaflets were cut using personalized templates be- data, a 3D model of the AVNeo cusp was created using 3D fore the initiation of the bypass (Video 1). The principle of implan- Modelling Software. It was converted into a two-dimensional im- tation is similar to the original Ozaki technique [1]. CT-guided age. Dimensions along the sewing margin were enlarged by B. Todurov et al. / Interdisciplinary CardioVascular and Thoracic Surgery 3 Video 1: Preparation and implantation of the computed tomography-guided aortic valve neocuspidization leaflets. Figure 2: Cine-MR ‘on-valve plane’ view acquired 3 months postoperatively. The perfect geometry and function of the valve are demonstrated. AVNeo: aor- tic valve neocuspidization. of 12/7 mmHg (Video 2). Magnetic resonance imaging control af- ter 3 months showed excellent geometry of the AVNeo valve with good mobility and coaptation of the cusps (Fig. 2). DISCUSSION The technical improvements in cardiac imaging methods over Video 2: Reinforcement of the commissures and final evaluation of the result. Postoperative transthoracic echocardiography control is demonstrated. the last decades have led to the increasing popularity of 3D visu- alization (3DV) in interventional cardiology and cardiac surgery [5]. At the same time, data on the application of preoperative AVNeo leaflets are smaller than standard Ozaki ones, approxi- 3DV for the production of personalized devices to treat heart mately by one-quarter. Plication while suturing should still be per- valve pathology are scarce [5]. formed, but not as extensive as with the original AVNeo. The growing interest in the AVNeo procedure is based on a Commissures were reinforced with three oval-shaped 6 mm 3 number of peculiar advantages of the method [1]. Preservation of mm 1.5 mm polytetrafluoroethylene pledgets usually utilized for left ventricle outflow tract mobility, large CZ, and absence of au- standard valve replacement (Video 2). The final evaluation was toimmune response to glutaraldehyde-treated autopericardium performed by transoesophageal echocardiography after weaning are among the factors that resulted in excellent haemodynamic from the bypass. It demonstrated a symmetric AVNeo valve with performance and a low complication rate of AVNeo up to the a transvalvular gradient of 14/8 mmHg and a trace aortic mid-term [1, 2]. At the same time, AVNeo is one of the most insufficiency. complex procedures in the surgery of the AV. Prolonged ischae- Each step of the concomitant CABG (left internal mammary mic time is an important disadvantage of the method [3, 4]. The artery-to-left anterior descending and saphenous vein grafts to preparation of the leaflets alone may constitute up to 20% of the obtuse marginal 1 and posterior descending artery) was per- ischaemic time [3]. Patients with combined cardiac pathology formed in a standard manner. who require concomitant procedures constitute up to 43% of the cohort [1]. Reduction of the ischaemic time in this subgroup is es- pecially important. RESULTS Another drawback of the original AVNeo is the measurement of the intercommissural distances on the collapsed aorta. The Aortic cross-clamp and bypass times were 108 and 151 min, re- true dimensions, configuration and spatial relationships of the spectively. The patient had an uneventful postoperative course. Intensive Care Unit stay was 2 days. The hospital stay after sur- different structures of the AR may be estimated only when it is gery was 7 days. Transthoracic echocardiography control at distended under physiologic blood pressure. During cross-clamp, 1 month after discharge demonstrated the perfect function of the all these characteristics significantly change. To mimic their actual AVNeo valve with trace insufficiency and transvalvular gradient size, the surgeon is recommended to put some pressure on the ADULT CARDIAC 4 B. Todurov et al. / Interdisciplinary CardioVascular and Thoracic Surgery sizer while taking the measurement [1]. This manoeuvre is diffi- Conflict of interest: none declared. cult to standardize and carries potential bias towards either over- or underestimated data. Data availability There were previously reported experiences in the preopera- tive use of 3DV for planning and sizing AVNeo [3, 6, 7]. They This publication is based on our experience with one patient. The demonstrated the feasibility of CT scanning for accurate preoper- data underlying this article are available in the article and in its ative procedure measurements. online supplementary material. We developed a method of CT-guided AVNeo permitting planning of the procedure and development of the patient- specific leaflets before the initiation of the bypass. Our method Reviewer information completely preserves the positive characteristics of the original Ozaki technique. At the same time, it has several essential advan- Interdisciplinary CardioVascular and Thoracic Surgery thanks Markus Krane tages. A CT image of the configuration and size of the aortic an- and the other, anonymous reviewer(s) for their contribution to the peer re- nulus is obtained in the diastolic phase of the cardiac cycle when view process of this article. AVNeo leaflets will distend and close. This is an ideal environ- ment for the surgical team to familiarize themselves with the unique patient anatomy, plan the procedure, and develop REFERENCES patient-specific AVNeo implants. They are closer in size to the [1] Ozaki S, Kawase I, Yamashita H, Uchida S, Takatoh M, Kiyohara N. native aortic leaflets than the original Ozaki ones. Their implanta- Midterm outcomes after aortic valve neocuspidization with tion requires lesser plication and may be performed faster. All glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc these factors contribute to a reduction of the ischaemic and by- Surg 2018;155:2379–87. pass time. As in our patient, they were 108 and 151 min, respec- [2] Pirola S, Mastroiacovo G, Arlati F, Mostardini G, Bonomi A, Penza E et al. tively. These data completely fall within standard limits for Single center five year’s experience of Ozaki procedure: midterm follow- up. Ann Thorac Surg 2021;111:1937–43. surgical AVR. Personalized templates provide an understanding [3] Pirola S, Mastroiacovo G, Mostardini G, Bonomi A, Guglielmo M, of the size of the autopericardial flap sufficient to perform the Muscogiuri G et al. Preoperative Ozaki technique measures on tridimen- procedure. This permits the prevention of the harvesting of an sional engineered root. J Cardiovasc Comput Tomogr 2022;16:51–3. excessive amount of tissue. The three-pledget technique is a sim- [4] Vijayan J, Lachma R, Rao P, Bhat A. Autologous pericardial aortic valve ple and fast method to reinforce neocommisures and ensure reconstruction: early results and comparison with mechanical valve re- placement. Indian J Thorac Cardiovasc Surg 2020;36:186–92. valve competence. [5] Bernhard B, Illi J, Gloeckler M, Pilgrim T, Praz F, Windecker S et al. We consider CT-guided AVNeo as a step towards greater per- Imaging-based, patient-specific three-dimensional printing to plan, sonalization of the Ozaki procedure. Our patient successfully train, and guide cardiovascular interventions: a systematic review and underwent a CT-guided AVNeo with concomitant CABG. meta-analysis. Heart Lung Circ 2022;31:1203–18. [6] Tsujimoto T, Tedoriya T, Okada K. Virtual reality-guided aortic valve leaf- Excellent postoperative haemodynamic and clinical results prove let reconstruction for type 0 bicuspid aortic stenosis. Interact CardioVasc the correctness of the preoperative measurements. However, Thorac Surg 2022;34:1152–4. we acknowledge that a greater number of clinical observations [7] Shearn A, Ordonez M, Rapetto F, Caputo M, Biglino G. Rapid prototyp- and longer follow-up are warranted to prove the viability of the ing flexible aortic models aids sizing of valve leaflets and planning the concept. Ozaki repair. JACC Case Rep 2020;2:1137–40.
Interactive Cardiovascular and Thoracic Surgery – Oxford University Press
Published: Jan 9, 2023
Keywords: Aortic stenosis; Aortic valve neocuspidization; Ozaki procedure; Personalized treatment
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