First-in-Man Use of Sutureless Perceval Valve for Endocarditis after Ozaki Procedure: A Bail-Out Strategy in Redo Infectious Aortic Valve Surgery

1. Introduction

Since its development, the Ozaki procedure, an autologous pericardial aortic valve reconstruction, has steadily gained recognition as a landmark innovation in aortic valve surgery. Initially conceived for younger patients to optimize valve hemodynamics and eliminate the need for prosthetic material, its indications have broadened considerably. Today, it is increasingly adopted in older and high-risk populations, offering a compelling alternative to conventional valve replacement thanks to its excellent mid-term outcomes, native-like valve dynamics, and the absence of prosthetic-related complications. Among the potential drawbacks, infective endocarditis (IE) remains the most serious and life-threatening complication of this technique. Although rare, IE carries a significant clinical burden and frequently necessitates complex reintervention in hostile anatomical environments. In a recent large single-center series from Toho University Ohashi Medical Center (2025), Fujikawa-Osaki et al. identified 40 reoperations due to endocarditis among 1,333 patients treated with the Ozaki procedure, yielding an incidence of 0.45% per patient-year [1]. This underscores both the rarity and clinical gravity of such a complication. Concurrently, the emergence of sutureless valve technology, particularly the Perceval Sutureless bioprosthesis (Corcym, Saluggia, Italia), has reshaped the approach to complex aortic valve reoperations [2]. As noted by Elgharaby et al. [3], the Perceval valve is being increasingly utilized in endocarditis settings, particularly in cases involving degenerated or infected prosthetic valves. Thanks to its inherent advantages including shortened cross-clamp time, streamlined deployment, and minimal annular manipulation, make it particularly valuable in fragile, inflamed, or infected tissue beds, where conventional suturing techniques risk paravalvular leakage or annular injury.

We present the first-in-man case of Perceval valve implantation as a bail-out solution for infective endocarditis following prior Ozaki reconstruction in a critically ill patient. This unique scenario highlights the potential synergy between two innovative techniques and expands therapeutic options for managing complex infective aortic pathology in the re-operative setting.

2. Case report

A 68-year-old male with a previous surgical history of Ozaki aortic valve reconstruction and LIMA-LAD coronary artery bypass grafting in 2023 for bicuspid aortic valve disease presented with acute decompensated heart failure. Blood cultures yielded Streptococcus bovis, and transesophageal echocardiography (TOE) revealed torrential aortic regurgitation due to destruction of the anterior neocuspidal leaflet, with associated large, mobile vegetations. (Figure 1)

The patient experienced rapid clinical deterioration, progressing to multiorgan failure characterized by septic and cardiogenic shock, acute hepatic dysfunction (shock liver), acute renal failure, septic encephalopathy, disseminated intravascular coagulation, and new-onset atrial flutter. Despite a calculated in-hospital mortality risk of 89.5% based on the EuroSCORE II, the severity of the clinical scenario mandated immediate salvage surgery. A redo median sternotomy was undertaken in a technically complex setting, complicated by the absence of the pericardium and dense mediastinal adhesions from the previous surgery. Careful and meticulous dissection allowed for the safe identification of the great vessels. Central cannulation was achieved via the aortic arch for arterial return and bicaval venous access for drainage. Cardiopulmonary bypass (CPB) was initiated under normothermic conditions, ensuring adequate systemic perfusion. The aorta was cross-clamped, and a transverse aortotomy was performed. Myocardial protection was provided through the administration of cold blood cardioplegia directly into the coronary ostia, with repeated doses to maintain optimal myocardial preservation throughout the procedure. Intraoperative exploration revealed extensive destruction: the left neocuspidal leaflet was completely perforated, and a large, highly mobile vegetation was found on the ventricular aspect of the valve. Furthermore, a sub- annular abscess was identified, extending from the left–right commissure into both the left and right sinuses of Valsalva. Radical debridement of all infected and necrotic tissue was undertaken, with evacuation of purulent material. The abscess cavity was meticulously excised until only macroscopically healthy tissue remained. The resulting defect, involving the annular region and extending approximately one centimeter into both sinuses, was reconstructed using two layers of continuous 4-0 Prolene sutures. Given the fragility of the annular tissue and the extensive debridement required, the use of a conventional sutured bioprosthesis was deemed inadvisable. A medium-sized Perceval sutureless bioprosthetic valve was therefore selected and deployed successfully. The aortotomy was closed using the Blalock technique with two layers of 5-0 Prolene sutures. Weaning from CBP proved challenging due to biventricular dysfunction in the context of preoperative multiorgan failure. As a result, femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was instituted intraoperatively to provide circulatory support and facilitate end-organ recovery. The total cross-clamp time was 58 minutes whilst CBP time was 125 minutes. Hemodynamic stabilization was gradually achieved, and ECMO was successfully explanted after 5 days. The patient remained in the intensive care unit for three weeks, during which progressive clinical improvement was observed. Transthoracic echocardiography performed prior to ICU discharge demonstrated normal function of the implanted Perceval valve (Figure 2 and Figure 3), with no evidence of paravalvular leakage or residual vegetations. At three-month follow-up, the patient remained clinically stable, and repeat imaging confirmed preserved valve function without signs of recurrent endocarditis.

3. Conclusion

Given the growing global uptake of the Ozaki procedure and the predictable, if rare, occurrence of endocarditis-related failure, the availability of a safe and efficient bailout strategy is essential. Our case supports the notion that the Perceval valve may fulfill this role, especially in patients with annular damage, calcification, or tissue friability that complicates conventional valve reimplantation.