Turkish Journal of Thoracic and Cardiovascular Surgery 2019;27(4):451-453
http://dx.doi.org/doi: 10.5606/tgkdc.dergisi.2019.01903

Video Article / Video Makalesi

Ozaki Procedure
Ozaki Prosedürü
Cem AlhanDepartment of Cardiovascular Surgery, Acıbadem University, School of Medicine, İstanbul, Turkey

Numerous randomized-controlled (also controlledby the industry giants) trials have shown that, interms of short-term outcomes, transcatheter aortic
valve implantation (TAVI) offers a suitable alternative
to the current gold standard of surgical aortic valve
replacement (SAVR), even in low-risk patients.
However, the main limitation of these trials is that thefollow-up period is limited to 12 months alone.[1,2] Ina review of nearly 14,000 patients, five-year survival
after TAVI was found to be 48%.[3] Compared tothe expected survival for a general population ofsimilar age, this study demonstrated poorer survival
outcomes after TAVI. In their recent meta-analysis
comparing SAVR and TAVI in low- and intermediaterisk patients, Ueshima et al.[4] demonstrated similar
all-cause mortality, cardiac mortality, and neurologicalevents during a two-year follow-up. Although the shortterm results have been well-studied in the literature,
there is a limited number of data regarding long-term
outcomes following TAVI, and with the unknown
transcatheter valve durability, TAVI should not beoffered to low-risk young patients, until long-term
follow-up data are available.

taken not to damage the heart, phrenic nerve, and thepericardium, itself.
Pericardium is attached on the plate with a roughsurface facing upwards. It must be stretched withthreads to avoid shrinking during fixation.
Diaphragmatic side of the pericardium is marked as
the larger leaflets would be made from this side, whichis thicker.
The pericardium is soaked in 0.6% glutaraldehyde
solution for 10 min. It is, then, rinsed with saline for six
min and this process is repeated three times.
A template of the pericardium is taken to close thepericardial defect at the end of the operation.
The aortic root is dissected free from the pulmonary
artery. Aortotomy site is marked which must be 15 mm
distal to the right coronary artery orifice.

Thus, SAVR is still the most optimal option for
the great majority of patients who needs aortic valve
replacement. In this video, the technical details ofneocuspidization of the aortic valve (Ozaki procedure)
will be presented.

SURGICAL TECHNIQUE (Video)
After a midline sternotomy, at least a 7¥8 cm
pericardium should be harvested. Adipose tissue overthe pericardium should be removed. Care must beVideo. Video showing all steps of Ozaki procedure.

Received: September 26, 2019 Accepted: September 30, 2019 Published online: October 23, 2019
Correspondence: Cem Alhan, MD. Acıbadem Maslak Hastanesi Kalp ve Damar Cerrahisi Bölümü, 34457 Maslak, İstanbul, Turkey.
Tel: +90 542 - 513 19 47 e-mail: calhan@gmail.com
Cite this article as:Alhan C. Ozaki Procedure. Turk Gogus Kalp Dama 2019;27(4):451-453©2019 All right reserved by the Turkish Society of Cardiovascular Surgery.

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Turk Gogus Kalp Dama
2019;27(4):451-453

A transverse aortotomy is made. The distance
between the right end of the incision and the left
coronary cusp (LCC)-non-coronary cusp (NCC)
commissure must be 10 mm.

suture is passed from the top corner of the other cusp
and, then, the aorta. Thus, there remains four threads
outside the aortic wall. A 5¥10 mm pledget is used to
fix the threads to the aortic wall.

For exposure, the distal aorta must be retracted witha pledgeted suture and the aortic retractors are placed.

A good reconstruction must end in a “windmill”
shape.

Calcified aortic cusps are removed completely withmaximal respect to the annular integrity. If necessary,
an ultrasonic device may be used for decalcification.
Each intercommissural length is measured
appropriately with the sizers. The midpoint of eachannulus is marked.
Treated pericardium is placed on plate witha smooth surface facing upwards. The cusps areprepared according to the corresponding window on
the template. Guiding dots are placed for every suturesite.
Pericardium is attached on a piece of paper for easy
handling during cutting. Each cusp is placed into thecorresponding part of the petri dish filled with saline.
Suturing is started from the right coronary cusp
which is most challenging. A 4-0, 90 cm polypropylene
suture with a TF 13 mm, 1/2 circle needle is used forsuturing. The first suture is passed from the midpointof the cusp to the midpoint of the annulus. The cusp is
dropped into the ventricle and the thread is tied withthree knots.
Suturing is always from upside to downside on
the annulus and vice versa on the cusp with a smoothsurface of the cusp facing the left ventricle.
For the first three to four stictches on the annulus
side, the distance between two stictches must be one
third of the corresponding cusp distance, which gives
the cusp a bird-nest shape. After this point where theremaining cusp and annulus lengths are the same,the distance between two stictches must be the sameon both sides. The last stitch on the annulus must
be a big bite for a better commissural support. After
penetrating the last dot, the needle is straightened by
the help of a needle-holder and passed 2.5 mm below
the top of the commissure.
The other cusps are sutured in the same manner.
For the commissures, a 4-0, 90 cm polypropylene
suture with an RB-1 17 mm, 1/2 circle needle is used.
This suture is placed at the midpoint between the freeedge and the previous stitch (approx. 2.5 mm fromedge) on one cusp and passed from the same site on
the opposing cusp and, then, from the top corner of thewing, and lastly from the aorta. The other end of the452

Comment
There are several advantages of the Ozaki procedure.
First, there is no foreign body including a suture ring.
It has been demonstrated that natural movement of
the aortic annulus is preserved, and the reconstructedaortic valve has significantly less pressure gradients,compared to conventional aortic valve replacementcases due to maximal effective orifice area, which isparticularly important in patients with a small aorticannulus. This technique can be also applied to almost
all aortic valve pathologies. There is no need for
warfarin postoperatively, and low-dose aspirin is used
for three to six months.
On the other hand, the major drawback of thetechnique is the unknown durability. In a recent
study, Ozaki et al.[5] reported their experience in
850 consecutive patients operated for aortic stenosis,
some of them with additional procedures (43.6%).
The median age was 71 years and the mean follow-up
was 53.7±28.2 months. The actuarial freedom fromdeath, cumulative incidence of reoperation, and thatof recurrent moderate-to-severe aortic regurgitation
was 85.9%, 4.2%, and 7.3%, respectively, with thelongest follow-up of 118 months. The authors reported
no conversion to a prosthetic valve replacement, andonly one of 850 patients underwent reoperation forstructural valve degeneration.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect tothe authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.

REFERENCES
1. Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK,Russo M, et al. Transcatheter aortic-valve replacement with aballoon-expandable valve in low-risk patients. N Engl J Med
2019;380:1695-705.
2. Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H,
O’Hair D, et al. Transcatheter aortic-valve replacement witha self-expanding valve in low-risk patients. N Engl J Med
2019;380:1706-15.
3. Chakos A, Wilson-Smith A, Arora S, Nguyen TC, Dhoble
A, Tarantini G, et al. Long term outcomes of transcatheter

Alhan.
Ozaki Procedureaortic valve implantation (TAVI): a systematic review
of 5-year survival and beyond. Ann Cardiothorac Surg
2017;6:432-43.
4. Ueshima D, Fovino LN, D’Amico G, Brener SJ,
Esposito G, Tarantini G. Transcatheter versus surgicalaortic valve replacement in low- and intermediate-riskpatients: an updated systematic review and meta-analysis.
Cardiovasc Interv Ther 2019;34:216-225
5. Ozaki S, Kawase I, Yamashita H, Uchida S, TakatohM, Kiyohara N. Midterm outcomes after aortic valve
neocuspidization with glutaraldehyde-treated autologous
pericardium. J Thorac Cardiovasc Surg 2018;155:2379-87.

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