Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium to avoid the prosthesis-patient mismatch of a severely obese 57-year-old patient—a case report

Abstract

Aortic valve repair is the gold standard for aortic valve diseases and it is mandatory, every time it is possible, to spare the valve, especially in adults. In non-repairable aortic valves, the most common treatment is replacement with valve prostheses. Despite the risk of reoperation, bioprosthesis are often implanted in non-elderly adults. The durability of the bioprostheses in youngers is lower than in the elderlies. Immune reaction, shear stress and calcium metabolism can play a fundamental role in degeneration.The alternative to prosthetic aortic valve replacement is the Ross procedure, which apparently is the best option for this patient, but its complexity combined with the need for intervention on both aortic and pulmonary valves have limited the use of this technique over time. A more recent alternative is aortic valve neocuspidization, as outlined by Ozaki, which consists in aortic valve reconstruction using glutaraldehyde treated autologous pericardium. Seen the recent positive outcomes reported with this technique, we decided to submit the patient, an obese 57 years old female affected by severe rheumatic aortic valve stenosis and moderate mitral valve stenosis, to this procedure. Our idea was to reduce the risk of prosthesis-patient mismatch (PPM) that this patient faced, seen that she had a small aortic annulus, but a high body mass index. Results have been great: aortic valve gradients were low at discharge and at follow up. Learning from this case, we can assert that this kind of surgery can be safely performed achieving superior hemodynamic results and quality of life. Thus, we did not perform many cases of Ozaki neocuspidization, we always looked for the "perfect patient": young, without big comorbidities, thin. The case we describe obliged us to face with a problem that today's surgeons find out more and more in their clinical practice: obesity in young adults. It is a matter of fact that when a prosthetic valve is implanted the risk of PPM is always behind the corner for the valve structure itself and the big amount of prosthetic material it is composed by. Performing echocardiography and angio CT scan in patients who underwent aortic valve neocuspidization the effective orifice of the valve and the transvalvular gradients where always lower than in those patients who underwent replacement with a prosthesis. This fact has been the starting point for the thought that, maybe, Ozaki technique is the best solution for obese patients and this case proved us right.

Outcomes of Ozaki Procedure/Aortic Valve Neocuspidization for Aortic Valve Diseases: A Systematic Review

“…There have been conflicting outcomes in Baird et al 33 when employing autologous pericardium for aortic valve surgery. Albertini et al 34 presented their long-term outcomes of aortic valve replacement utilizing autologous pericardium treated in 0.2% glutaraldehyde for 10 minites with a 33% reoperation rate. In a similar treatment plan to that described by Ozaki, Carotti 38 reported the long-term outcomes of the leaflet extension approach employing autologous pericardium.In that series, a 15% reoperation rate after 7 years was seen in 41 patients with a mean age of 32 years, indicating that autologous pericardial patches may outlast bioprosthetic aortic valves in younger individuals.…”

Tissue requirements for the application of aortic valve neocuspidization – appropriate pericardium properties and homogeneity?

“…In particular the physiological movement of the aortic annulus through the cardiac cycle after AVNeo has to be highlighted [ 5 , 12 ]. Due to the 10–15-year durability of conventional bioprostheses fabricated from bovine pericardium, especially for younger patients that have the risk for necessary re-operation, the use of autologous pericardium is a promising alternative [ 2 , 13 ]. A discussed increase of free margin lengths of the cusps in AVNeo can be the basis for a greater utility even for pediatric populations with continued aortic annular growth [ 1 , 14 , 15 ].…”

“…A discussed increase of free margin lengths of the cusps in AVNeo can be the basis for a greater utility even for pediatric populations with continued aortic annular growth [ 1 , 14 , 15 ]. But also adult or elderly patients with an increased risk of prosthesis-patient mismatch e. g. with extreme anatomical specificities may profit from the surgical technique using autologous material [ 5 , 13 ]. Nevertheless, in 2022 a first case with the need for re-operation after AVNeo was published describing the calcification of the cusps at the annulus positions [ 16 ].…”

Reflecting on the lessons learned in Bologna: Surgery of the Thoracic Aorta

“…Albertini et al (1) described their experience with aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium in a severely obese 57-year-old female patients with history of acute articular rheumatism in her childhood, who rapidly showed signs of dyspnoea and angina following moderate physical exertion a month prior to the operation. TTE revealed severe aortic stenosis, which was later confirmed by TEE.…”

“…The authors stated that this technique is a safe and effective treatment choice for aortic valve disease in non-elderly patients and is a feasible alternative to aortic valve replacement with biological or mechanical valve as well as the Ross procedure. Yet, randomized trials and larger observational studies are needed in the future to confirm these findings as evidence in the literature on use of autologous pericardium is currently limited (1).…”