Rationale and results of the Stanford modification of the David V reimplantation technique for valve-sparing aortic root replacement

Abstract

Even though the concept of valve-sparing aortic root replacement was introduced 35 years ago, confusion still exists about the strengths and weaknesses of the different surgical procedures used when relatively normal aortic cusps call for replacing the aortic root and preserving the regurgitant aortic valve rather than replacing the valve with a composite valve graft. Valve-sparing aortic root replacement operations are subdivided into 2 general families: (1) the Yacoub ‘‘remodeling’’ technique used since 1979 and (2) the David ‘‘reimplantation’’ technique performed since 1988. Innumerable individual modifications of the David reimplantation procedure have been described, but many surgeons are still unclear about the rationale behind these different approaches and what they strive to accomplish. At the base, all reimplantation methods firmly anchor the aortic graft proximally at theventriculoaortic junction below the leaflets in the left ventricular outflow tract with the commissures sewn inside the polyester fabric graft. This is unphysiologic because it abolishes the pronounced 3-dimensional dynamicmotion of the normal aortic annulus, but the annulus cannot dilate postoperatively, causing recurrent aortic regurgitation (AR). To Tirone David’s chagrin, in 2003 I attempted to track the evolution of his personal surgical valve-sparing techniques. The ‘‘David I’’ is the original reimplantation procedure, which uses a 26to 30-mm cylindrical tube graft. The ‘‘David II’’ and ‘‘David III’’ are variations of Yacoub’s remodeling procedure (the David III incorporated a strip of polytetrafluoroethylene felt externally across the base of the noncoronary sinus from trigone to trigone of themitral valve tominimize subsequent annular