Page 29 - BH-3-3

Brain & Heart Modern imaging and management of bicuspid valves

mechanical valves are known for their long-term durability during follow-up. In a study by Poh et al., 129 patients
86
87
and resistance to degeneration, making them ideal for with BAV and isolated AR underwent the Ross procedure.
younger patients who require a more permanent solution. At a 20-year follow-up, 85% remained free from aortic
Regarding surgical approaches, a median sternotomy valve reoperation and more-than-mild AR. 87
provides excellent exposure and is a well-established A recent meta-analysis comparing the Ross procedure
technique, commonly used in complex cases.
to mechanical and bioprosthetic AVR showed that the
The limitation of bioprosthetic valves is that they have Ross procedure demonstrated significantly lower all-cause
a shorter lifespan, particularly in younger patients, which mortality compared to mechanical AVR (Hazard ratio:
may necessitate reoperation after several years. Mechanical 0.58; 95% confidence interval: 0.35 – 0.97; p=0.035) and
valves, while durable, require lifelong anticoagulation, bioprosthetic AVR (Hazard ratio: 0.32; 95% confidence
increasing the risk of bleeding and thromboembolic interval: 0.18 – 0.59; p<0.001). Reintervention rates were
events. Regarding surgical approaches, median sternotomy, lower with the Ross procedure and mechanical AVR than
though providing excellent exposure, is associated with with bioprosthetic AVR, but higher for the Ross procedure
longer recovery times and a higher risk of complications. than mechanical AVR. The Ross procedure also showed
In contrast, hemi-sternotomy and mini-thoracotomy offer reduced rates of major bleeding, long-term stroke, and
smaller incisions and faster recovery but demand greater endocarditis compared to mechanical and bioprosthetic
surgical expertise and may not be suitable for all patients, AVR. These findings reinforce the Ross procedure as a
88
especially those with complex conditions. Aortic valve durable and effective alternative for appropriately selected
84
repair is an alternative to valve replacement for patients patients with BAV, particularly when performed by skilled
with aortic valve disease, particularly in cases of AR or surgeons in experienced centers.
certain forms of AS, where the valve leaflets are repairable.
The procedure aims to preserve the patient’s native valve, A key strength of the Ross procedure is that it provides
avoiding the need for lifelong anticoagulation therapy excellent long-term outcomes, particularly in younger
required with mechanical valves and providing better patients, as the autograft aortic valve grows with the
long-term durability compared to bioprosthetic valves. 81 patient and has a lower risk of degeneration compared to
bioprosthetic valves. In addition, it avoids the need for
85
5.3. The Ross procedure lifelong anticoagulation, as the patient’s tissue is used.
The Ross procedure, initially developed in 1967, is However, a major limitation is the technical complexity
gaining attention as a promising option for patients of the procedure, which requires considerable surgical
requiring AVR, particularly among younger individuals expertise. There is also a risk of pulmonary valve
with BAV who lack annuloaortic ectasia and wish to dysfunction over time, necessitating potential reoperation.
avoid lifelong anticoagulation. This operation involves However, it requires two valve replacements and carries
replacing the aortic valve with the patient’s pulmonary the potential for pulmonary autograft complications. 42
root (autograft) and using a homograft to replace the 5.4. Ozaki procedure
pulmonary valve. Although technically challenging and
85
requiring advanced expertise in aortic root dynamics The Ozaki procedure is a more recent innovation, in which the
and anatomy, the procedure offers the advantage of long- aortic valve is replaced with a tissue-engineered valve made
term valve durability and improved clinical outcomes from autologous pericardium. This procedure aims to offer
when performed in specialized centers. A key concern the benefits of valve repair while addressing the limitations
following the Ross procedure is the long-term durability of conventional valve replacement, including the risk of valve
89
of the pulmonary homograft and the potential for early degeneration. Both the Ross and Ozaki procedures provide
autograft failure or recurrent AR. In a study conducted by viable options for patients requiring aortic valve intervention,
Hanke et al. involving 1,277 Ross procedure recipients especially for younger patients requiring long-term durability
86
(mean age 42.2 years) in Germany, 71% had BAV, with without anticoagulation. It also preserves the patient’s native
presentations including isolated stenosis, regurgitation, aortic root, which is beneficial for aortic root dilation.
or mixed disease. Patients were treated with either sub- However, the Ozaki procedure is technically demanding
coronary implantation or full root replacement. The and may be associated with variable long-term outcomes,
analysis revealed no significant difference in early post- particularly in terms of durability and valve function, with
operative AR or its progression between BAV patients a higher incidence of reoperation seen in some studies. 90,91
and those with tricuspid valves, regardless of surgical Both procedures are complex and unsuitable for all patients,
technique. Nonetheless, BAV patients were more likely to with outcomes heavily dependent on the surgeon’s experience
experience progressive dilation of the annulus and sinus and patient selection.

Volume 3 Issue 3 (2025) 10 doi: 10.36922/BH025050008