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\title{Ozaki Procedure for the treatment of Aortic Valve Endocarditis : A
Life-saving Alternative}



\author[1]{Harun Arbatli}%
\author[2]{Ali Kubilay Korkut}%
\author[1]{Okan Coskun}%
\author[3]{Cem Alhan}%
\affil[1]{Hizmet Hospital (Memorial)}%
\affil[2]{Halic University}%
\affil[3]{Acibadem Hospitals Group}%


\vspace{-1em}



  
  \date{April 30, 2026}


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\selectlanguage{english}
\begin{abstract}
Infective endocarditis (IE) still has a high risk of mortality and
morbidity, despite of developments in medical treatment. Intracranial
hemorrhage is one of serious complication, which has poor outcome. We
present a 30-year-old male with diagnosis of IE. He had severe aortic
regurgitation and oscillating vegetations on both side of the aortic
valve. Although there was no neurological symptom in preoperative
period, cranial magnetic resonance imaging (MRI) revealed millimetric
size ischemic lesions at the right cerebral hemisphere. We performed
Ozaki procedure. However, cerebral hemorrhage occurred on the first
postoperative day. Computerized tomography (CT) revealed hematoma in
parietal and occipital lobes. He was treated with conservative
anti-edema therapy and discharged from the hospital on the 25th day with
minor visual defect of his eye. Echocardiography control revealed mild
aortic regurgitation without any other pathologic finding after 18
months. Aortic neocuspidization by using using of glutaraldehyde treated
autologous pericardium decreases the risk of fibrosis and calcification,
and thrombosis events. Possibility of suspending the anticoagulant and
antiplatelet regimen is a significant advantage in this type of repair.
Ozaki procedure might be the first-choice surgical reconstruction
technique in anatomically suitable IE cases.%
\end{abstract}%



\sloppy


\textbf{Ozaki Procedure for the treatment of Aortic Valve Endocarditis
:}

\textbf{A Life-saving Alternative}

Harun Arbatl\selectlanguage{polish}ı\selectlanguage{english}*, Ali Kubilay Korkut**, Okan Co\selectlanguage{polish}ş\selectlanguage{english}kun*, Cem Alhan***

* Hizmet Hospital (Memorial), Dept.of Cardiovasc. Surg., Istanbul,
Turkey

** Halic University Med. Fac., Dept.of Cardiovasc. Surg., Istanbul,
Turkey

*** Acibadem University Med. Fac., Dept.of Cardiovasc. Surg., Istanbul,
Turkey

Corresponding

Ali Kubilay Korkut, MD

Halic University Med. Fac.

S\selectlanguage{ngerman}ütlüce Mah. Imrahor Cad. No.82, Beyoglu, Istanbul, Turkey

Tlf. 0-90-532 3368277

e.mail. kubilaykrkt@gmail.com

Word count. 1358

Abstract

Infective endocarditis (IE) still has a high risk of mortality and
morbidity, despite of developments in medical treatment. Intracranial
hemorrhage is one of serious complication, which has poor outcome.

We present a 30-year-old male with diagnosis of IE. He had severe aortic
regurgitation and oscillating vegetations on both side of the aortic
valve. Although there was no neurological symptom in preoperative
period, cranial magnetic resonance imaging (MRI) revealed millimetric
size ischemic lesions at the right cerebral hemisphere. We performed
Ozaki procedure. However, cerebral hemorrhage occurred on the first
postoperative day. Computerized tomography (CT) revealed hematoma in
parietal and occipital lobes. He was treated with conservative
anti-edema therapy and discharged from the hospital on the
25\textsuperscript{th} day with minor visual defect of his eye.
Echocardiography control revealed mild aortic regurgitation without any
other pathologic finding after 18 months. Aortic neocuspidization by
using using of glutaraldehyde treated autologous pericardium decreases
the risk of fibrosis and calcification, and thrombosis events.
Possibility of suspending the anticoagulant and antiplatelet regimen is
a significant advantage in this type of repair. Ozaki procedure might be
the first-choice surgical reconstruction technique in anatomically
suitable IE cases.

Key words. Infective endocarditis, aortic valve endocarditis, Ozaki
procedure

Introduction

IE is a deadly, and despite improvements in its management, remains
associated with high mortality and morbidity. Neurological complications
occur in 20-40\% of patients during IE and have been related with poorer
outcome (1). Vegetation size \selectlanguage{english}[?] 3cm, mitral valve involvement, S. aureus
as the causal pathogen and anticoagulant treatment are risk factors
associated with neurological complications (2). Tornos et al. proved in
their study that in left-sided IE due to S aureus anticoagulant therapy
is strongly correlated with death to neurologic damage, which as a rule
occurs early in the course of the disease (3). We present an aortic
valve involved IE in a young male patient, who occurred intracranial
hemorrhage following Ozaki procedure. Approval by the Institutional
Review Board and informed consent were waived according to our
institutional policies for anonymized case reports.

Case Report

A 30-year-old male patient was admitted with the diagnosis of aortic
valve endocarditis. He had shortness of breath and his functional
capacity was in NHYA class III. Second degree AV block (Mobitz II) was
seen on electrocardiography. Transthoracic and transesophageal
echocardiography revealed a bicuspid aortic valve with severe
regurgitation, an oscillating vegetation with 0.8x1.1 cm diameter
located on the aortic side of the non-coronary cusp, and mild mitral
regurgitation (Figure 1a and Figure 1b). Although the patient was
asymptomatic neurologically, cranial diffusion MRI revealed millimetric
size ischemic lesions at the right cerebral hemisphere.

Blood cultures were negative. Ampicillin/sulbactam (2g ampicillin + 1g
sulbactam iv q6hr) and gentamicin (3mg/kg/day iv q12hr) was given for
empiric antibiotic treatment. Furosemide (20mg iv q12hr) and dopamine
perfusion (3\selectlanguage{greek}µ\selectlanguage{english}g/kg/min iv) were started. Congestive heart failure
symptoms were improved in the first two weeks, but severe aortic
regurgitation persisted, and a complete AV block occurred for a
short-time period no need for pace-maker, urging us for surgery.

Operative technique and postoperative period

Standart median sternotomy, aortic and two-stage right atrial
cannulation was carried out. Moderate hypothermia and extracellular
crystalloid cardioplegia were used for myocardial protection. The aortic
valve was bicuspid, and the non-coronary cusp had ruptured. Both cusps
and all the infected annular tissue were excised. There was no abscess
formation. Ozaki procedure was performed by using glutaraldehyde treated
autologous pericardium (4) (Figure 2a and Figure 2b). Perioperative
trans-esophageal echocardiography revealed mild aortic regurgitation.

While weaning from the ventilator; visual agnosia and right sided
hemiparesis were recognized. CT revealed intracranial hematoma in the
parietal and occipital lobes (Figure 3). Neurological symptoms improved
following anti-edema therapy. 3\% NaCl infusion was given to achieve a
blood sodium concentration of 145-155mEq/L. The patient was discharged
on the postoperative 25\textsuperscript{th} day. All motor functions of
the right upper extremity recovered in six months; however, he still has
a minor visual defect of the left eye.

Aortic tricuspid valve reconstruction (Figure 4a) and mild aortic
regurgitation (Figure 4b) were seen on trans-thoracic echocardiography
at postoperative 18\textsuperscript{th} month.

Discussion

Despite improvements in medical and surgical treatment, long term
mortality and morbidity of IE still remain high (5). Surgical
intervention is considered necessary and has significantly improved the
survival especially in patients with cardiac failure, drug resistant
infections, persistent vegetations, recurrent embolic events, and
prosthetic valve endocarditis (5). Furthermore, prognosis is better in
case of early surgical intervention, before cardiac tissue destruction
and deterioration occurs (5).

Neurological complications occur in 20\% to 40\% of IE patients, and a
predict a poor clinical outcome (2). Cessation of anticoagulation should
be considered in concomitant bleeding (3).

Valve replacement or preferably valve repair is necessary in aortic
valve IE patients. The use of artificial materials should be avoided as
much as possible. Stentless valves, aortic homografts or the Ross
procedure may be considered in cases with periannular supporting tissue
destruction (5). However, especially in younger patients, early
degeneration of bioprosthesis occurs due to fibrosis, calcification or
immune reactions (6).

Ozaki and coworkers defined an aortic valve reconstruction technique
using autologous pericardium treated with glutaraldehyde (7). In this
technique all leaflets are resected, and new pericardial leaflets are
reconstructed separately for each coronary cusp. Treatment of this
pericardial tissue with glutaraldehyde has been shown to decreases the
risk of fibrosis and calcification, and thrombo-embolic events in the
long term.

The choice of Ozaki procedure enabled us to avoid anticoagulant and
antiplatelet therapy, which gave the best chance of survival in IE
patient complicated with a postoperative hemorrhagic cerebrovascular
event.

Conclusion

We assume that the Ozaki procedure should be the first-choice surgical
reconstruction technique in anatomically suitable IE cases. Long term
results of the Ozaki procedure are promising with 12 years of follow-up
(8).

Acknowledgements

We would like to thank scrub-nurse Mrs. Leyla K\selectlanguage{polish}ı\selectlanguage{english}l\selectlanguage{polish}ı\selectlanguage{ngerman}ç for her support
during the whole surgical procedure.

Conflict of Interests

All the authors declare that there is no conflict of interests.

References

\begin{enumerate}
\tightlist
\item
  Heiro M, Nikoskelainen J, Engblom E, Kotilainen E, Marttila R,
  Kotilainen P. Neurological manifestations of infected endocarditis: a
  17-year experience in a teaching hospital in Finland. Arch Intern Med.
  2000;160:2781-2787.
\item
  Garcia-Cabrera E, Fernandez-Hidalgo N, Almirante B, Ivanova-Georgieva
  R, Noureddine M, Plata A. et.al. Neurological Complications of
  Infective Endocarditis. Risk Factors, Outcome, and Impact of Cardiac
  Surgery: A Multicenter Observational Study. Circulation
  2013;127:2272-2284.
\item
  Tornos P, Almirante B, Mirabet S, Permanyer G, Pahissa A, Soler-Soler
  J. Infective Endocarditis Due to Staphylococcus aureus: Deleterious
  Effect of Anticoagulant Therapy. Arch Intern Med. 1999;159(5):473-475.
\item
  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 Jun;155(6):2379-2387.
\item
  Netzer RO, Altwegg SC, Zollinger E, Tauber M, Carrel T, Seiler C.
  Infective endocarditis: Determinants of long term outcome. Heart,
  2001;88:61-66.
\item
  Khan SS, Trento A, DeRobertis M, Kass RM, Sandhu M, Czer LS et al.
  Twenty-year comparison of tissue and mechanical valve replacement. J
  Thorac Cardiovasc Surg. 2001;122:257-269.
\item
  Alhan C. Ozaki procedure. Turkish J Thorac Cardiovasc Surg
  2019;27(4):451-453.
\item
  Ozaki S. Ozaki procedure: 1100 patients with up to 12 years of
  follow-up. Turkish J Thorac Cardiovasc Surg 2019:27(4):454.
\end{enumerate}

Figures\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1a. Transthoracic echocardiography revealed the vegetation
located on the aortic side of the non-coronary cusp of a bicuspid aortic
valve (white arrow)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 1b. Aortic valve with severe regurgitation is seen on
preoperative transthoracic echocardiography.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 2a. Neo-aortic cusps are reconstructed using
glutaraldehyde-treated autologous pericardium\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Figure 2b. Pericardial cusps are sutured to the aortic annulus.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

Figure 3. CT revealed intracranial hematoma in the left parietal and
occipital lobes.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

Figure 4a. Aortic tricuspid valve reconstruction is seen on
postoperative transthoracic echocardiography.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}

Figure 4b. Transthoracic echocardiography revealed mild regurgitation on
postoperative 18\textsuperscript{th} month (white arrow).

\selectlanguage{english}
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