Simplified David Reimplantation With Reduction of Anular Size and Creation of Artificial Sinuses

Abstract

The David reimplantation procedure is the preferred method of preserving tricuspid aortic valves during aortic root replacement. We report the results of a simplified approach to the David valve-sparing root reimplantation. Of 234 patients who underwent David reimplantation or some modification thereof, 129 operated on from January 2001 to June 2008 formed a consecutive single-surgeon series for midterm evaluation. Aortic anulus-left ventricular outflow tract and proximal tube graft size were reduced over a Hegar dilator to mean normal diameter based on body surface area, in the process creating neo-sinuses to accommodate cusp opening. Sixty-one patients (47%) had Marfan syndrome. Mean body surface area was 2.1 +/- 0.27 m(2). Preoperative aortic regurgitation grade was 1+ or less in 46%, 2+ in 26%, 3+ in 24%, and 4+ in 4.3%. Left ventricular outflow tract sizing by Hegar dilator was 17 mm in 9.5% of patients, 19 mm in 18%, 21 mm in 56%, and 23 mm in 16%. Fifty-five (43%) had concomitant cusp repair. Postoperative aortic regurgitation grade was 0 in 98%, and none of the remaining had greater than 2+ AR. Postoperative mean aortic gradient was 9.0 +/- 3.5 mm Hg. No patient had intraoperative abandonment of the repair, and there were no postoperative deaths or strokes. Five-year survival was 99%, and 4 patients (3%) required late valve replacement. A simple modification of the David operation, reducing anular size, and creating neo-sinuses preserves the aortic valve, eliminates aortic regurgitation, avoids aortic stenosis, and has favorable midterm results.