Aortic valve neo-cuspidation using the Ozaki technique for acquired and congenital disease: where does this procedure currently stand?

  • 28 Accesses


The surgical treatment options for pediatric aortic valve disease are limited. The Ozaki procedure, which involves templated creation of new aortic valve leaflets, has proved to be a promising surgical technique. This review aims at elaborating the indications, technical intricacies, and outcomes of the aortic valve neo-cuspidization procedure (Ozaki procedure) in the pediatric population.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9


  1. 1.

    Baird CW, Myers PO, del Nido PJ. Aortic valve reconstruction in the young infants and children. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2012;15:9–19.

  2. 2.

    Bacha EA, McElhinney DB, Guleserian KJ, et al. Surgical aortic valvuloplasty in children and adolescents with aortic regurgitation: acute and intermediate effects on aortic valve function and left ventricular dimensions. J Thorac Cardiovasc Surg. 2008;135:552–9.

  3. 3.

    D’Udekem Y. Aortic valve surgery in children. Heart. 2011;97:1182–9.

  4. 4.

    Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–607.

  5. 5.

    Ozaki S, Kawase I, Yamashita H, et al. Aortic valve reconstruction using self-developed aortic valve plasty system in aortic valve disease. Interact Cardiovasc Thorac Surg. 2011;12:550–3.

  6. 6.

    About AVNeo [Internet]. Available from:

  7. 7.

    Mourad F, Shehada SE, Lubarski J, et al. Aortic valve construction using pericardial tissue: short-term single-centre outcomes. Interact Cardiovasc Thorac Surg. 2019;28:183–90.

  8. 8.

    Makkar RR, Fontana G, Søndergaard L. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2016;374:1591–2.

  9. 9.

    Chakravarty T, Søndergaard L, Friedman J, de Backer O, Berman D, Kofoed KF, et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet. 2017;389:2383–92.

  10. 10.

    Kawase I, Ozaki S, Yamashita H, Uchida S, Nozawa Y, Matsuyama T, et al. Aortic valve reconstruction of unicuspid aortic valve by tricuspidization using autologous pericardium. Ann Thorac Surg. 2012;94:1180–4.

  11. 11.

    Ozaki S, Kawase I, Yamashita H, Uchida S, Nozawa Y, Takatoh M, et al. Reconstruction of bicuspid aortic valve with autologous pericardium - usefulness of tricuspidization. Circ J. 2014;78:1144–51.

  12. 12.

    Ozaki S, Kawase I, Yamashita H, et al. Aortic valve reconstruction using autologous pericardium for patients aged less than 60 years. In: J Thorac Cardiovasc Surg. 2014;148:934–8.

  13. 13.

    Ozaki S, Kawase I, Yamashita H, Uchida S, Takatoh M, Kiyohara N. Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg. 2018;155:2379–87.

  14. 14.

    Reuthebuch O, Koechlin L, Schurr U, Grapow M, Fassl J, Eckstein FS. Aortic valve replacement using autologous pericardium: single centre experience with the Ozaki technique. Swiss Med Wkly. 2018;148:w14591.

  15. 15.

    Nguyen DH, Vo AT, Le KM, Vu TT, Nguyen TT, Vu TT, et al. Minimally invasive ozaki procedure in aortic valve disease: the preliminary results. Innovations (Phila). 2018;13:332–7.

  16. 16.

    Rossekyn (Personal Communication, Sept 2019).

  17. 17.

    Baird CW, Sefton B, Chavez M, Sleeper LA, Marx GR, del Nido PJ. Congenital aortic and truncal valve reconstruction utilizing the Ozaki technique: short-term clinical results. J Thorac Cardiovasc Surg. 2019; In press.

  18. 18.

    Mazzitelli D, Nöbauer C, Rankin JS, Vogt M, Lange R, Schreiber C. Complete aortic valve cusp replacement in the pediatric population using tissue-engineered bovine pericardium. Ann Thorac Surg. 2015;100:1923–5.

  19. 19.

    Cheng A, Dagum P, Miller DC. Aortic root dynamics and surgery: from craft to science. Philos Trans R Soc Lond Ser B Biol Sci. 2007;362:1407–19.

  20. 20.

    Rodriguez F, Green GR, Dagum P, et al. Left ventricular volume shifts and aortic root expansion during isovolumic contraction. J Heart Valve Dis. 2006;15:465–73.

  21. 21.

    Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967;2:956–8.

  22. 22.

    Pasquali SK, Cohen MS, Shera D, Wernovsky G, Spray TL, Marino BS. The relationship between neo-aortic root dilation, insufficiency, and reintervention following the Ross procedure in infants, children, and young adults. J Am Coll Cardiol. 2007;49:1806–12.

  23. 23.

    Sharabiani MTA, Dorobantu DM, Mahani AS, et al. Aortic valve replacement and the Ross operation in children and young adults. J Am Coll Cardiol. 2016;6724:2858–70.

  24. 24.

    Etnel JR, Elmont LC, Ertekin E, et al. Outcome after aortic valve replacement in children: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2016;151:143–52.

  25. 25.

    Myers PO, Mokashi SA, Horgan E, Borisuk M, Mayer JE Jr, del Nido P, et al. Outcomes after mechanical aortic valve replacement in children and young adults with congenital heart disease. J Thorac Cardiovasc Surg. 2019;157:329–40.

  26. 26.

    Saleeb SF, Newburger JW, Geva T, Baird CW, Gauvreau K, Padera RF, et al. Accelerated degeneration of a bovine pericardial bioprosthetic aortic valve in children and young adults. Circulation. 2014;130:51–60.

  27. 27.

    Duran CMG.Aortic valve repair and reconstruction. Oper Tech Card Thorac Surg.1996;1:15-29.

  28. 28.

    Cosgrove D, Fraser C. Aortic valve repair. Oper Tech Card Thorac Surg.1996;1:30-37.

  29. 29.

    El Khoury G, Vanoverschelde JL, Glineur D, et al. Repair of bicuspid aortic valves in patients with aortic regurgitation. Circulation. 2006;114:I-610-I–6.

  30. 30.

    Polimenakos AC, Sathanandam S, Blair C, ElZein C, Roberson D, Ilbawi MN. Selective tricuspidization and aortic cusp extension valvuloplasty: outcome analysis in infants and children. Ann Thorac Surg. 2010;90:839–46.

  31. 31.

    Duran CMG, Gallo R, Kumar N. Aortic valve replacement with autologous pericardium: surgical technique. J Card Surg. 1995 Jan;10(1):1–9.

  32. 32.

    Kalfa D, LaPar D, Chai P, Bacha E. Aortic valve neocuspidization: a bright future in pediatric aortic valve surgery? J Thorac Cardiovasc Surg. 2019;157:728.

  33. 33.

    Schoen FJ, Levy RJ. Calcification of tissue heart valve substitutes: progress toward understanding and prevention. Ann Thorac Surg. 2005;79:1072–80.

  34. 34.

    Myers PO, Tissot C, Christenson JT, Cikirikcioglu M, Aggoun Y, Kalangos A. Aortic valve repair by cusp extension for rheumatic aortic insufficiency in children: long-term results and impact of extension material. J Thorac Cardiovasc Surg. 2010;140:836–44.

  35. 35.

    Baird CW, Myers PO, Piekarski B, et al. Photo-oxidized bovine pericardium in congenital cardiac surgery: single-centre experience. Interact Cardiovasc Thorac Surg. 2017;24:240–4.

  36. 36.

    Schoen FJ. Pathologic findings in explanted clinical bioprosthetic valves fabricated from photooxidized bovine pericardium. J Heart Valve Dis. 1998;7:174–9.

  37. 37.

    Prabhu S, Armes JE, Bell D, et al. Histologic evaluation of explanted tissue-engineered bovine pericardium (CarddioCel). Semin Thorac Cardiovasc Surg. 2017;29:356–63.

  38. 38.

    Chivers SC, Pavy C, Vaja R, Quarto C, Ghez O, Daubeney PEF. The Ozaki procedure with CardioCel patch for children and young adults with aortic valve disease: preliminary experience – a word of caution. World Journal for Pediatric and Congenital Heart Surgery. 2019;10(6):724–30.

Download references

Author information

Correspondence to Christopher W. Baird.

Ethics declarations

Compliance with ethical standards

Dr. Baird has no financial relationship with JMODD but has participated in JMODD sponsored training of centers in the Ozaki procedure.

Conflict of interest

The authors declare that they have no conflicts of interest. Dr. Baird has no financial relationship with JMODD but has participated in JMODD sponsored training of centers in the Ozaki procedure.

Ethical statements, human and animal rights, and informed consent

Not required being a review article.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Baird, C.W., Marathe, S.P. & del Nido, P.J. Aortic valve neo-cuspidation using the Ozaki technique for acquired and congenital disease: where does this procedure currently stand?. Indian J Thorac Cardiovasc Surg 36, 113–122 (2020).

Download citation


  • Ozaki procedure
  • Aortic valve neo-cuspidization
  • Aortic valve repair/reconstruction
  • AVNeo