OBJECTIVE: Three-dimensional (3D) modelling of aortic leaflets remains difficult due to insufficient resolution of medical imaging. We aimed to model the coaptation and load-bearing surfaces of the aortic leaflets and adapt this workflow to aid in the design of aortic valve neocuspidizations.
METHODS: Geometric morphometrics, using landmarks and semilandmarks, was applied to the geometric determinants of the aortic leaflets from computed tomography, followed by an isogeometric analysis using Non-Uniform Rational Basis Splines (NURBS). Ten aortic valve models were generated, measuring determinants of leaflet geometry defined as 3D NURBS curves, and leaflet coaptation and load-bearing surfaces were defined as 3D NURBS surfaces. Neocuspidizations were obtained by either shifting the upper central coaptation landmark towards the sinotubular junction or using parametric neo-landmarks placed on a centreline drawn between the centroid of the aortic root base and centroid of a circle circumscribing the 3 upper commissural landmarks.
RESULTS: The ratio of the leaflet free margin length to the geometric height was 1.83, whereas the ratio of the commissural coaptation height to the central coaptation height was 1.93. The median coaptation surface was 137 mm2 (IQR 58) and the median load-bearing surface was 203 mm2 (60) per leaflet. Neocuspidization multiplied the central coaptation height by 3.7 and the coaptation surfaces by 1.97 and 1.92 using the native coaptation axis and centroid coaptation axis, respectively.
CONCLUSIONS: Geometric morphometrics reliably defined the coaptation and load-bearing surfaces of aortic leaflets, enabling an experimental 3D design for the in silico neocuspidization of aortic valves.

BACKGROUND: The original Ozaki technique involves sizing the neovalve cusps during cross-clamp. It leads to prolonging the ischemic time compared to standard surgical AVR. Measurements taken on the collapsed Aortic Root (AR) may also be inaccurate. We use preoperative Computed Tomography (CT) to perform more accurate sizing in physiological conditions and shorten the ischemic time. This study analyzes the results of the CT-guided Aortic Valve Neocuspidization (AVNeo) compared with the Ozaki technique.
METHODS: The validity of the concept was evaluated ex vivo. Experimental valves underwent geometric, CT, and hydrodynamic controls. In the clinical phase of the study, we prospectively analyzed patients who received CT-guided AVNeo (N ​= ​7, Group 1). The control group enrolled patients who were operated on after the standard AVNeo technique (N ​= ​15, Group 2).
RESULTS: In Group 1, Aortic Cross-Clamp (70.3 ​± ​17.0 vs. 91 ​± ​21.3 ​min, ρ ​= ​0.026) and Bypass times (92.9 ​± ​21.0 vs. 123 ​± ​24.8 ​min, ρ ​= ​0.011) were significantly shorter. At discharge, the peak (11.7 ​± ​2.75 vs. 15.4 ​± ​4.66 ​mm Hg, ρ ​= ​0.032) and mean Aortic Valve (AV) gradient (6.29 ​± ​1.25 vs. 7.87 ​± ​2.33 ​mm Hg, ρ ​= ​0.052) were lower in Group 1. Only one patient in Group 2 had Aortic Insufficiency (AI) greater than mild. The mean follow-up was 49.6 ​± ​6.9 months in both groups. There were no late deaths or any valve-related events detected in any patient. EchoCG revealed that peak (10.0 ​± ​2.65 vs. 12.6 ​± ​4.05 ​mm Hg, ρ ​= ​0.090) and mean AV gradient (5.14 ​± ​1.35 vs. 6.73 ​± ​2.25 ​mm Hg, ρ ​= ​0.054) also were lower in Group 1. AI indexes were stable in both Groups.
CONCLUSIONS: CT-guided AVNeo is an example of personalized medicine in the surgical treatment of heart valve pathology. It allows the development of a biological AV that adapts to the patient\'s anatomy, shortens ischemic time, and results in better hemodynamics. A more significant number of clinical observations and longer follow-up are warranted to prove the viability of the concept.

BACKGROUND: Aortic valve reconstruction using glutaraldehyde-treated autologous pericardium, also called Ozaki procedure, is a surgical procedure for patients with aortic valve disease. Gratifying results have been reported in adult patients, however, limited published data is available in paediatric population. This study looked at clinical characteristics and early outcomes of children who underwent Ozaki procedure at our Institute.
METHODS: This was a retrospective descriptive study conducted on children who underwent aortic valve reconstruction at Jakaya Kikwete Cardiac Institute (JKCI) from January 2019 through December 2022. Medical records of these children were reviewed to extract data on demographics, clinical characteristics, redo surgical interventions and survival.
RESULTS: A total of 10 children underwent Ozaki procedure during the study period. Eight children had severe aortic regurgitation while 2 had severe aortic stenosis preoperatively. All children had either none or trivial aortic regurgitation immediately after surgery. None of them had redone operations throughout the follow-up period. There was no in-hospital mortality, however, one child died one-year after surgery. The mean follow-up period was 1.6 years with the longest follow-up time of 4 years.
CONCLUSIONS: Ozaki procedure showed encouraging early results among children with aortic valve disease who underwent surgical repair by this technique. Future studies with larger sample sizes and longer follow up periods to evaluate long-term results in this population are recommended.

Aortic valve disease is often treated with bioprosthetic valves. An alternative treatment is aortic valve neocuspidization which is a relatively new reparative procedure whereby the three aortic cusps are replaced with patient pericardium or bovine tissues. Recent research indicates that aortic blood flow is disturbed, and turbulence effects have yet to be evaluated in either bioprosthetic or aortic valve neocuspidization valve types in patient-specific settings. The aim of this study is to better understand turbulence production in the aorta and evaluate its effects on laminar and turbulent wall shear stress. Four patients with aortic valve disease were treated with either bioprosthetic valves (n=2) or aortic valve neocuspidization valvular repair (n=2). Aortic geometries were segmented from magnetic resonance images (MRI), and 4D flow MRI was used to derive physiological inlet and outlet boundary conditions. Pulsatile large-eddy simulations were performed to capture the full range of laminar, transitional and turbulence characteristics in the aorta. Turbulence was produced in all aortas with highest levels occurring during systolic deceleration. In the ascending aorta, turbulence production is attributed to a combination of valvular skew, valvular eccentricity, and ascending aortic dilation. In the proximal descending thoracic aorta, turbulence production is dependent on the type of arch-descending aorta connection (e.g., a narrowing or sharp bend) which induces flow separation. Laminar and turbulent wall shear stresses are of similar magnitude throughout late systolic deceleration and diastole, although turbulent wall shear stress magnitudes exceed laminar wall shear stresses between 27.3% and 61.1% of the cardiac cycle. This emphasises the significance of including turbulent wall shear stress to improve our comprehension of progressive arterial wall diseases. The findings of this study recommend that aortic valve treatments should prioritise minimising valvular eccentricity and skew in order to mitigate turbulence generation.

BACKGROUND: Trileaflet aortic valve neocuspidization (AVN) using autologous pericardium (Ozaki procedure) is an emerging surgical treatment option for aortic valve diseases. Although excellent results have been reported from Japan, data pertaining to its use in the United States are sparse.
METHODS: All adult patients who underwent AVN (AVN group) or surgical aortic valve replacement (SAVR) with a bioprosthetic valve (SAVR group) between 2015 and 2022 were identified. Propensity score matching was used to adjust the baseline characteristics between the 2 groups.
RESULTS: A total of 101 patients underwent AVN, and 1816 patients underwent SAVR with a bioprosthetic valve. None in the AVN group required conversion to SAVR. Before matching, mean age in the AVN group was 68.5 ± 8.8 years, and 56 patients (55.4%) underwent concomitant procedures. Preoperatively, 3 (3%) had endocarditis. Bicuspid valve was observed in 38 (38.4%). None died at 30 days in the AVN group. The median follow-up duration was 3.2 years. After propensity score matching, the expected survival and freedom from at least moderate aortic regurgitation at 5 years was 91.7% ± 3.1% and 97.6% ± 1.7%, respectively. Propensity score matching yielded 77 patients in each group. The Kaplan-Meier curve demonstrated equivalent survival at 5 years between the 2 groups (P = .95). Additionally, freedom from at least moderate aortic regurgitation was comparable at 5 years (P = .23).
CONCLUSIONS: AVN can be safely performed for a variety of aortic valve diseases, with or without concomitant operations. AVN demonstrated similar midterm outcomes compared with SAVR with a bioprosthetic valve in the United States adult population.

The Ozaki procedure has emerged as a valuable option for treating various aortic valve pathologies. This review article delves into the intricacies of this innovative surgical approach by exploring its adaptation to the complex anatomy and physiology of the aortic root. The diverse etiologies of aortic valve diseases, ranging from congenital anomalies to degenerative changes, make treatment selection a complex challenge. Aortic valve replacement has traditionally been the gold standard, but emerging evidence supports valve repair techniques, emphasizing the importance of preserving native tissue. Nevertheless, issues like lifelong anticoagulation with mechanical valves and patient-prosthetic mismatch remain. The Ozaki procedure offers a compelling alternative by utilizing autologous pericardium or a tissue substitute to construct new aortic valve leaflets. This technique, standardized by Dr. Ozaki in 2007, provides a customizable and adaptable solution. The article highlights the anatomy of the aortic root, emphasizing the critical role of the sinus of Valsalva and interleaflet triangles in maintaining proper valve function. The procedure\'s unique adaptation to aortic root dynamics allows for reduced mechanical stress during systole and diastole, mimicking the natural valve\'s behavior. Furthermore, Ozaki leaflets exhibit promising hemodynamics and reduced risks of complications, such as permanent pacemaker implantation and patient-prosthetic mismatch. The use of autologous pericardium in the Ozaki procedure presents advantages, including enhanced tissue strength, minimal immunogenicity, and reduced risk of immune-mediated calcification. These factors contribute to the longevity and resilience of the reconstructed valve. This comprehensive review aims to shed light on the procedure\'s intricacies, its alignment with aortic root anatomy and physiology, and its potential as a valuable tool in the armamentarium of aortic surgeons.

The surgical treatment options for pediatric aortic valve disease are limited and have debatable long-term durability. In the current situation, the Ross procedure is considered in children for aortic valve disease(s). It is a complex surgical procedure with the risk of neo-aortic dilatation, converting a single valve disease into double valve disease, and associated with future re-interventions. Conversely, the Ozaki procedure has shown promising results in adults. Thus, the present study aimed to provide comparative evidence on the effectiveness and safety of the Ozaki versus Ross procedure for pediatric patients by performing a meta-analytic comparison of reporting outcomes. A total of 15 relevant articles were downloaded and among them, seven articles (one prospective study, five retrospective studies, and one case series) were used in the analysis. Primary outcomes such as physiological laminar flow pattern and hemodynamic parameters, and secondary outcomes such as hospital stays, adverse effects, mortality, and numbers of re-intervention(s) were measured in the meta-analysis. There were no significant differences in the age of patients between children who underwent the Ozaki procedure and those who underwent the Ross procedure at the time of surgeries. The Ozaki procedure is a good solution to an aortic problem(s) similar to the Ross procedure. Unlike the Ross procedure, the Ozaki procedure has restored a physiological laminar flow pattern in the short-term follow-up without the bi-valvular disease. Mean hospital stays (p = 0.048), mean follow-up (p = 0.02), adverse effects (p = 0.02), death, and numbers of re-intervention(s) of children who underwent the Ozaki procedure were fewer than those who underwent the Ross procedure. The time required for re-intervention(s) is higher for children who underwent the Ozaki procedure than those who underwent the Ross procedure. None of the procedures, including the Ozaki procedure for aortic valve disease(s), has significant effects on hemodynamic parameters and the frequent death rate of children after surgeries. Based on our analysis, we may suggest the Ozaki procedure for aortic valve disease surgery in children.

Aortic valve neocuspidization, initially described by Ozaki and colleagues, has become an increasingly popular treatment approach for aortic valve disease in both adult and paediatric populations. We report a case of an 18-year-old man with severe aortic regurgitation who underwent the Ozaki procedure using photo-oxidized bovine pericardium. Around 5 weeks after the surgery, he developed early symptomatic valve failure due to multiple leaflet tears requiring urgent reoperation.

UNASSIGNED: In 2014, Ozaki et al. introduced the neo-cuspidation (Ozaki procedure), a new valve from the pericardium, to reduce or even prevent the risk of chronic autoimmune inflammation and subsequent rejection or valve degeneration. Thus, the authors aimed to assess the safety and efficacy of the Ozaki technique in treating aortic valve diseases.
UNASSIGNED: A comprehensive search was performed via PubMed, the Cochrane Library, Scopus, and the Web of Science up to 20 February 2022. Random-effects meta-analysis models were employed to estimate the pooled mean and SD or event to the total of the Ozaki procedure. Relevant records were retrieved and analyzed by OpenMeta analyst software.
UNASSIGNED: A total of 2863 patients from 21 studies were finally included in our analysis. Ac. Ozaki technique showed statistical significance in terms of mean cardiopulmonary bypass time of 148 mins (95% CI 144-152.2, P<0.001), mean aortic cross-clamp time of 112.46 mins (95% CI 105.116, 119.823, P<0.001), reoperation with a low risk of 0.011 (95% CI 0.005, 0.016, P=0.047), conversion to aortic valve replacement with a low risk of 0.004 (95% CI -0.001, 0.008, P=0.392), finally ICU stay (days) and hospital length of stay (days) with a mean of 2.061 days (95% CI 1.535, 2.587, P<0.001) and 8.159 days (95% CI 7.183-9.855, P<0.001), respectively.
UNASSIGNED: The Ozaki procedure provides a safe surgical technique with low mean cardiopulmonary bypass time and aortic cross-clamp time; moreover, a mean of 2-day-postoperative hospital stay was observed with the Ozaki procedure with a low risk of conversion to aortic valve replacement, reoperation, ICU and hospital stay, and death.

We report a 19-year-old woman with a history of percutaneous aortic valve (AV) balloon valvuloplasty 3 years ago. She was admitted with severe symptomatic AV stenosis with narrow aortic annulus. We decided to perform AV reconstruction with autologous pericardium. However, surgical findings revealed a very narrow AV annulus with a unicuspid valve; therefore, an AV enlargement was added.