Aortic Valve Bicuspidization in a Unicuspid Aortic Valve

For children facing the challenges of aortic valve disease, the surgical landscape has historically presented limited options, each with its own set of long-term uncertainties. The Ross procedure, often considered the gold standard, carries its own complexities. This intricate surgery involves the transfer of the pulmonary valve to the aortic position, followed by the replacement of the pulmonary valve with a homograft. This introduces risks such as neoaortic root dilation and neopulmonary regurgitation. Another layer of complexity is added by the scarcity of homografts in developing countries. Furthermore, this procedure transforms a single valve issue into a double valve scenario, potentially increasing the need for future interventions (1, 3).  

Other avenues, such as biological valves, often falter in the dynamic environment of a child's growing body. Their rapid deterioration necessitates early reintervention, placing further burdens on young patients (2). 

Prosthetic valves also present their own set of hurdles. The small aortic annulus in pediatric patients, particularly those with aortic stenosis, combined with the imperative for lifelong anticoagulation, paints a challenging picture. This not only impacts the child's quality of life, but also carries the inherent risk of prosthetic valve failure and the need for further surgeries (3).  

The Ozaki procedure has yet to demonstrate robust long-term results in the pediatric population. Moreover, studies have indicated higher midterm complications compared to the Ross procedure, raising concerns about its overall efficacy in this age group; thus, it is considered a palliative or bridging surgery that may serve as a temporary solution until eventual replacement can be performed (4, 5). 

However, a new horizon is emerging: the bicuspidization of the diseased aortic valve. This innovative approach offers a promising and effective repair option, particularly crucial when homografts for the Ross procedure are unavailable. Even in redo cases, a small piece of autologous pericardium can be masterfully used to reconstruct the valve. This technique not only preserves the pliable portions of the native leaflets, allowing for potential growth, but also offers the promise of both reliability and durability (6). 

References

1. Abeln KB, Ehrlich T, Souko I, Brenner F, Schäfers HJ. Autograft reoperations after the Ross procedure. Eur J Cardiothorac Surg. 2023 May 2;63(5):ezad117. doi: 10.1093/ejcts/ezad117. PMID: 36971602; PMCID: PMC10162808.
2. Philip R, Kumar TK, Waller BR, McCoy M, Knott-Craig CJ. Near Catastrophic Accelerated Structural Degeneration of the Perimount Magna Pericardial Bioprosthesis in Children. Ann Thorac Surg. 2016 Jul;102(1):308-11. doi: 10.1016/j.athoracsur.2015.09.088. PMID: 27343502.
3. Etnel JR, Elmont LC, Ertekin E, Mokhles MM, Heuvelman HJ, Roos-Hesselink JW, de Jong PL, Helbing WA, Bogers AJ, Takkenberg JJ. Outcome after aortic valve replacement in children: A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2016 Jan;151(1):143-52.e1-3. doi: 10.1016/j.jtcvs.2015.09.083. Epub 2015 Sep 28. PMID: 26541831.
4. Wang GX, Zhang S, Ma K, Pang KJ, Wang X, Yang KM, Zhang BQ, Yang Y, Li SJ. Ozaki technique versus ross operation for complex aortic valve diseases in children: A retrospective cohort study. Int J Surg. 2024 Jul 18;111(1):113–21. doi: 10.1097/JS9.0000000000001959. Epub ahead of print. PMID: 39023753; PMCID: PMC11745767.
5. Halder V, Mishra A, Ghosh S, Singh H, Barwad P, Thingnam SK, Dutta ARS, Harunal M. Effectiveness and Safety of the Ozaki Procedure for Aortic Valve Disease in Pediatric Patients: A Systematic Review and Meta-Analysis. Cureus. 2023 Sep 14;15(9):e45269. doi: 10.7759/cureus.45269. PMID: 37846270; PMCID: PMC10576845.
6. Schäfers HJ, Aicher D, Riodionycheva S, Lindinger A, Rädle-Hurst T, Langer F, Abdul-Khaliq H. Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg. 2008 Jun;85(6):2012-8. doi: 10.1016/j.athoracsur.2008.02.081. PMID: 18498811.

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