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Aortic Valve Repair With All Cusp Replacement Using Treated Autologous Pericardium: The Ozaki Technique

Wednesday, August 21, 2019

Tambrallimath PR, Chatterjee S, Bose S. Aortic Valve Repair With All Cusp Replacement Using Treated Autologous Pericardium: The Ozaki Technique. August 2019. doi:10.25373/ctsnet.9589007.

Aortic valve reconstruction with glutaraldehyde-treated autologous pericardium has been demonstrated by Ozaki and colleagues to have good midterm results with less transvalvular gradient, less than mild aortic regurgitation, and 96.2% freedom from reoperation. The Ozaki technique uses an original template for each cusp designed by Ozaki, and the leaflets are trimmed according to the template size (1).

Inspired by the work of Ozaki et al for using glutaraldehyde-treated autologous pericardium and associated midterm results, the authors have developed a simple formula for the making of neo–aortic leaflets with 0.6% glutaraldehyde-treated autologous pericardium.

The patient was a 17-year-old girl with symptoms of dyspnea on exertion for one year, New York Heart Association class III symptoms, and a history of rheumatic fever two years previously. Echocardiography showed thickened, small, and retracted aortic leaflets with central coaptation defect and severe aortic regurgitation, vena contract of 7 mm, a dilated left ventricle, and normal left ventricular function. After examining the aortic valve, the authors decided to replace the diseased leaflets with 0.6% glutaraldehyde-treated autologous pericardial leaflets.

After excising the diseased aortic leaflets, the base of each cusp attachment to the annulus was measured with silk thread. The aortic annulus was measured with the aortic valve sizer. The authors converted the aortic valve sizer diameter directly into millimeters, and used it as a marker for the neocusp measurement. The valve-sizer diameter was used as the height and width of the neocusp free margin, and the silk thread was kept on the pericardium in an arc shape to fashion the neocusp as shown in the video. All three neocusps were created in this manner and then sutured to the respective cusp annulus with a 5-0 polypropylene suture in a continuous manner, and the suture was brought out at the commissure level. The suturing technique for the central part of the cusp to the annulus was in a 2:1 ratio, that is, 4 mm on the pericardium and 2 mm on the annulus. This created a nice puckering of the pericardium in the central part. For the ascending part of the annulus, the suturing was performed in a 1:1 ratio, that is, 2 mm on the pericardium and 2 mm on the annulus, and then the sutures were brought out at the commissure level. This was repeated for all three cusps. The sutures of the adjacent cusp were tied at the commissure level. Fine adjustments were made at the commissure level for any undulation or prolapse.

The postoperative echocardiography of this patient showed good coaptation, with the coaptation height of 9.4 mm, no residual aortic regurgitation, and aortic valve orifice area of 3.4 cm2. The patient was extubated after eight hours of ventilation and discharged from the hospital on postoperative day seven. Follow-up echocardiography at one month and at six months showed no aortic regurgitation, coaptation height of 1 cm, and good aortic valve orifice area.

The authors propose that this new technique of aortic valve repair with all cusp replacement using glutaraldehyde-treated autologous pericardium is durable, simple, reproducible, and economical, and it awaits midterm and long-term results.


  1. Ozaki S, Kawase I, Yamashita H, et al. A total of 404 cases of aortic valve reconstruction with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg. 2014 Jan;147(1):301-306.


The authors have to be commended for the result of this operation and the quality of the video. However, there is a problem when talking about this procedure shown by the authors. Authors state,like many others, that this is an aortic valve repair. Accoridng to the title of this video "Aortic Valve Repair With All Cusp Replacement Using Treated Autologous Pericardium: The Ozaki Technique", one can see a conceptual problem. Authors cannot repair something by replacement. According to any dictionary like the Cambridge, "Repair" is "to put something that is damaged, broken, or not working correctly, back into good condition or make it work again" and "Replacement" is "the process of replacing something with something else". Whatever is done here is to excise the native disease leaflets and replace them with another material, livign or dead, as authors have done in a very nice manner. Therefore, the Ozaki procedure is an aortic valve replacement, in this case using autologous pericardium that has been treated with something, like glutaraldehyde. We can use treated or untreated autologous pericardium, bovine pericardium, stentless or stended valves, homografts or autografts, but all of these, including the Ozaki procedure and its variants, are replacements. Congratulations again and we look forward for the long-term follow-up of this case as 6-months for a 17-year-old girl is still short. He will enjoy a good quality of life.
I appreciate the comment made by my friend Carlos Mestres, but, with all respects, this reflects all limits of the surgeons dealing with acquired heart diseases. The surgeons dealing with congenital heart defects are generally dealing with daily clinical problems, where there are not established solutions, or the options available are not exactly ideal, and therefore they have to look for alternative approaches, focusing on the surgical techniques and the potential outcomes, completely forgetting the terminology. in this specific case, we should say that the OZAKI technique, brilliantly illustrated by the colleagues, is not a repair neither a replacement. Carlos has already explained why it cannot be considered a "repair". But also the definition of "replacement" is not appropriate. Contrary to all other "replacements", with either a biological or a mechanical valve, the OZAKi techniques maintain the native aortic root and annulus, with all the well known advantages from the hemodynamic point of view, and therefore without all the drawbacks of any aortic valve "replacement". Not to mention the maintenance of an effective orifice area much better than any biological or mechanical valve. I suggest all the surgeons to consider the potential advantages of the OZAKI procedure, without focusing on the terminology. Antonio F. Corno

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