David Technique Research Articles

Functional interaction of aortic valve and ascending aorta in patients after valve-sparing procedures

Pressure recovery (PR) is essential part of the post stenotic fluid mechanics and depends on the ratio of EOA/AA, the effective aortic valve orifice area (EOA) and aortic cross-sectional area (AA). In patients with advanced ascending aortic aneurysm and mildly diseased aortic valves, the effect of AA on pressure recovery and corresponding functional aortic valve opening area (ELCO) was evaluated before and after valve-sparing surgery (Dacron graft implantation). 66 Patients with ascending aortic aneurysm (mean aortic diameter 57 +/− 10 mm) and aortic valve-sparing surgery (32 reimplantation technique (David), 34 remodeling technique (Yacoub)) were routinely investigated by Doppler echocardiography. Dacron graft with a diameter between 26 and 34 mm were implanted. EOA was significantly declined after surgery (3.4 +/− 0.8 vs. 2.6 +/− 0.9cm2; p < 0.001). Insertion of Dacron prosthesis resulted in a significant reduction of AA (26.7 +/− 10.2 vs. 6.8 +/− 1.1cm2; p < 0.001) with increased ratio of EOA/AA (0.14 +/− 0.05 vs. 0.40 +/− 0.1; p < 0.001) and pressure recovery index (PRI; 0.24 +/− 0.08 vs. 0.44 +/− 0.06; p < 0.0001). Despite reduction of EOA, ELCO (= EOA corrected for PR) increased from 4.0 +/− 1.1 to 5.0 +/− 3.1cm2 (p < 0.01) with reduction in transvalvular LV stroke work (1005 +/− 814 to 351 +/− 407 mmHg × ml, p < 0.001) after surgery. These effects were significantly better in patients with Yacoub technique than with the David operation. The hemodynamic findings demonstrate a valve-vessel interaction almost entirely caused by a marked reduction in the ascending AA with significant PR gain. The greater hemodynamic benefit of the Yacoub technique due to higher EOA values compared to the David technique was evident and may be of clinical relevance.

Preliminary results of a simplified aortic valve‐sparing technique: A feasibility study

To evaluate whether the simplified valve-sparing technique (SVST) implies clinical outcomes comparable or not with those of established David technique in the surgery of aortic root. We collected the records of patients who had undergone aortic root surgery with the SVST or standard David technique (SDT) at our institution between January 2009 and December 2018. The primary endpoints were the incidence of all-cause death, reoperation for any reason, and postoperative complications. The secondary endpoint was the midterm incidence of reoperation for aortic valve regurgitation. A total of 169 patients who underwent aortic root surgery were analyzed. SDT and SVST were performed in 48 (28.4%) and in 121 (71.6%) patients, respectively. Thirty-day mortality occurred in 0% and 0.8% of patients in the SDT and SVST groups, respectively. The rate of postoperative new permanent pacemaker implantation was 6.3% (three patients) and 0.8% (one patient) in SDT and SVST cohort, respectively (p = .07). The incidence of postoperative thromboembolic stroke was 6.3% and 2.5% in SDT and SVST groups, respectively (p = .23). The median follow-up time was 29 (23-47) months. During the FU period, no differences were found between two cohorts in terms of all-cause mortality (p = .99), the incidence of reoperation (p = .19), and incidence of aortic valve regurgitation requiring reoperation (p = .58). The SVST appears to be safe and feasible showing early clinical results comparable to the SDT. Nevertheless, further studies with larger series and long-term follow-ups are required to demonstrate its safety and efficacy.

Valve-sparing root replacement after the Ross procedure

ObjectivesThe Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients. MethodsPatients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared. ResultsForty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement. ConclusionsValve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed.

Ross procedure with pulmonary autograft reinforcement using reimplantation technique

Dilatation of the pulmonary autograft resulting in aortic valve regurgitation represents a common issue following Ross procedure with root replacement, in particular when performed beyond childhood. We present our early experience with modified Ross procedure associated with autograft reinforcement using reimplantation technique. Records of 59 consecutive patients who underwent Ross procedure with reinforcement between 2009 and 2021were analysed. Pulmonary autograft was reimplanted in a Dacron conduit of a median diameter = 26 mm (range: 20–30) using Tirone David's technique of valve sparing aortic root replacement (VSRR). Median age was 17 years (range: 6–38). Majority of cases has presented with mono or bicuspid aortic valve ( n = 50; 85%), predominant aortic valve regurgitation ( n = 38; 64%) and dilatation (> 30 mm) of the ascending aorta ( n = 32; 54%). Forty-six (78%) had at least one prior aortic valve procedure. No death occurred. Three patients required early procedure-related reoperation 8 others were reoperated on later resulting in 3 neo-aortic valve replacement all-over (5%). The mean duration of follow-up was 46 ± 12 months. Neither more than mild autograft regurgitation nor stenosis was observed. Mean diameters of the autograft annulus and sinotubular junction were respectively 24.8 ± 2.6 mm and 25.3 ± 2.1 mm at discharge and 25.3 ± 2.1 mm and 25.4 ± 2.7 mm at the last visit ( P = 0.06 and 0.08). Autograft reinforcement by means of reimplantation technique prevented neo-aortic root dilatation and allowed to extend the indications for Ross procedure to patients for whom the conventional Ross technique was qualified to be unsuitable. Early failure was rare (5%) and mid-term outcomes confirmed the stability of the neo-aortic valve function in follow-up.

Aneurysm of the aortic root and valve‑sparing aortic root replacement: long-term outcomes from a single Polish center.

Valve-sparing aortic root replacement (VSARR) techniques are an alternative to the classic Bentall procedure when aortic root aneurysm is not accompanied by aortic valve stenosis, and the regurgitant aortic valve is amenable to repair. The aim of the study was to assess long -term outcomes of valve sparing aortic root replacement using the David technique and the Yacoub technique. A total of 101 consecutive, elective VSARR procedures were performed from January 2010 to April 2020 including 52 David procedures (51.5%) and 49 Yacoub procedures (48.5%). We analyzed mortality, freedom from reoperation, and freedom from aortic valve regurgitation. The analysis was performed for the entire study cohort and for 2 subgroups: the David technique and the Yacoub technique. The mean (SD) age was 50.2 (16.1) years; 90 (89.1%) patients were male. The median (interquartile range [IQR]) EuroScore II was 3.7 (2.7‒5.8). At 1, 5, and 8 years after surgery, survival (SE) was 98% (3%), 91.8% (8%), and 91.8% (8%), respectively, whereas freedom from reoperation (SE) was 100%, 97% (3%), and 97% (3%), respectively. Follow‑up echocardiography performed at a median (IQR) of 18.7 (2.5‒36.7) months postsurgery revealed freedom from aortic valve regurgitation in 90.8% of patients. No significant differences in mortality, freedom from reoperation, and freedom from aortic valve regurgitation were noted between the David and Yacoub subgroups. VSARR is a safe and effective surgical technique in patients with aortic root aneurysm, as the associated mortality, reoperation rate, and aortic valve regurgitation recurrence are low.

Remote results of Florida Sleeve technique in patients with ascending aortic aneurysms and aortic insufficiency.

The aim of our investigation was to assess the remote results of valve-sparing aortic root reimplantation into the graft (Florida Sleeve technique) compared with reimplantation of the aortic valve into the graft (David technique) during surgical correction of ascending aortic aneurysms accompanied by concomitant aortic insufficiency. Our single-centre, blind, prospective, randomized study carried out from 2011 to 2015 included a total of 64 patients with ascending aortic aneurysms and aortic insufficiency. The patients were randomized into 2 groups: group I - aortic root reimplantation according to the Florida Sleeve technique (FS group) and group II - reimplantation of the aortic valve according to the T. David technique in David I modification (D group). The groups did not statistically differ by the baseline clinical profile. The overall 7-year survival for the FS group and D group amounted to 83% and 85.6%, respectively (p=0.98). Assessing the competing risks of mortality related to cardiovascular or other causes revealed no differences. Freedom from prosthetic repair of the aortic valve in the remote follow-up period amounted to 92.8% and 85.8% for the FS group and D group, respectively (p=0.4). According to the obtained findings, the technique of a valve-sparing operation is not a predictor of either lethality (RR 0.98 (95% CI 0.23-4.15), p=0.98) or prosthetic repair of the aortic valve (RR 2.03 (95% CI 0.40-14.63), p=0.40) in the remote period of follow up. Aortic root reimplantation inside the prosthesis according to the Florida Sleeve technique makes it possible to simplify and accelerate the procedure of aortic root reconstruction in patients with aortic root aneurysms and concomitant aortic insufficiency, demonstrating long-term results comparable with those of the David technique.

Extensive aortic surgery in acute aortic dissection type A on outcome \u2013 insights from 25 years single center experience

BackgroundThis single center study compares the different surgical techniques used in the treatment of acute aortic dissection type A (AADA) analyzing the influence of the extent of the surgical approach on outcome.MethodsFrom 1988 to 2012, 407 patients were operated for AADA. The cohort was divided into subgroups according to the surgical approach. These groups were compared with the supracommissural replacement group (SCR; n = 141). Groups included aortic valve sparing techniques (AVS; n = 29), Composite replacement (COMP; n = 119), COMP with total arch replacement (COMP+TAR; n = 27) and SCR with TAR (n = 75).ResultsCompared to SCR alone, operation (p = 0.005), bypass-, cross-clamp and circulatory arrest times were longer in SCR + TAR (all p < 0.001). Moreover, operation, bypass and cross clamp times were longer in COMP+TAR (p = 0.003, p = 0.002 and p < 0.001 respectively). COMP alone and AVS required longer cross-clamp time, too (p < 0,001 and p = 0.002, respectively). Overall 30-day mortality was 21% with the observed lowest rate after AVS (14%, SCR 18%, COMP 25%) but differences in 30-day mortality were not statistically significant. The estimated 10-year survival was 42%, especially AVS demonstrated a good 10-year survival (69%). David technique was superior to Yacoub technique concerning incidence of redo interventions (p = 0.036). Risk factors for early mortality included age, circulatory arrest, general malperfusion, bypass and operation time. Circulatory arrest per se was revealed as risk factor for long-term survival.ConclusionsWithin our single center retrospective study concomitant aortic root repair or aortic arch replacement for AADA demonstrated acceptable early and long-term survival. Circulatory arrest, long bypass and operation times per se might be important risk factors for early mortality. AVS techniques can be performed safely and have good outcomes in acute aortic dissection repair.

Biomechanical characterization and comparison of different aortic root surgical techniques.

Understanding the biomechanical impact of aortic valve-sparing techniques is important in an era in which surgical techniques are developing and are increasingly being used based on biomechanical understanding that is essential in the refining of existing techniques. The objective of this study was to describe how the valve-sparing remodelling (Yacoub) and reimplantation (David Type-1) techniques affect the biomechanics of the native aortic root in terms of force distribution and geometrical changes. Two force transducers were implanted into 22 pigs, randomized to 1 of 3 groups (David = 7, native = 7 and Yacoub = 8) along with 11 sonomicrometry crystals and 2 pressure catheters. Force and geometry data were combined to obtain the local structural stiffness in different segments of the aortic root. The radial structural stiffness was not different between groups (P = 0.064) at the annular level; however, the David technique seemed to stabilize the aortic annulus more than the Yacoub technique. In the sinotubular junction, the native group was more compliant (P = 0.036) with the right-left coronary segment than the intervention groups. Overall, the native aortic root appeared to be more dynamic at both the annular level and the sinotubular junction than both intervention groups. In conclusion, the David procedure may stabilize the aortic annulus more than the Yacoub procedure, whereas the leaflet opening area was larger in the latter (P = 0.030). No difference (P = 0.309) was found in valve-opening delay between groups. The 2 interventions show similar characteristics at the sinotubular junction, whereas the David technique seemed more restrictive at the annular level than the Yacoub technique.

Propensity-matched comparison between minimally invasive and conventional sternotomy in aortic valve resuspension†

The aim of the study was to compare the results of David procedure through conventional or minimally invasive approach. A propensity-matched comparison in patients undergoing a minimally invasive (partial upper sternotomy, n = 103) or complete sternotomy (n = 103) David procedure from 1991 to 2016 was performed. Patients were 57 ± 14 years old on average in both groups. The David technique was modified by generating a neosinus (P < 0.01) in 99 (96%) patients (minimally invasive group) and in 42 (41%) patients (complete sternotomy group), respectively. The average follow-up time was 3 ± 2 years (minimally invasive group) and 8 ± 4 years (complete sternotomy group). There was only 1 in-hospital death (in the full sternotomy group, P = 0.5). The applied quantity of packed red blood cells (pRBC) was significantly higher in the complete sternotomy group (3.4 ± 4 vs 1 ± 0.5, P < 0.01). There were no late deaths in the minimally invasive group but 14 died during a longer follow-up period in the full sternotomy group (P < 0.01). Freedom from reoperation or aortic valve insufficiency ≥2° was 95% vs 93% (minimally invasive versus complete sternotomy group) at 5 years and 95% vs 79% at 10 years (P < 0.01). The minimally invasive aortic valve reimplantation procedure for selected patients with aortic root aneurysm and aortic valve incompetence is a durable procedure with minor valve-related morbidity and mortality at the mid-term follow-up. The intra- and perioperative application of pRBC was significantly lower in the minimally invasive group. However, comparison of long-term follow-up data in both groups is necessary to evaluate valve function.

Midterm Results of a Minimally Invasive Approach in David Procedure.

The David procedure is a well-known technique in selected patients with aortic root pathology. A minimally invasive approach in heart surgery increases open interest. From 1991 to 2015, the David technique was performed in 296 patients in our unit. In 90 cases, operations were performed through partial upper sternotomy. The patient mean age was 57 ± 14 years in the minimally invasive group (n = 90) and 58 ± 14 years in the complete sternotomy group (n = 206; p = 0.2). The neosinus modification was performed in 80 patients (89%) in the minimally invasive group and in 79 patients (38%) in the complete sternotomy group (p < 0.01). Mean follow-up was 3 ± 2 years in the minimally invasive group and 8 ± 4 years in the complete sternotomy group. Thirty-day mortality was zero in the minimally invasive group and was 3% (n = 6) in the complete sternotomy group (p = 0.1). The need for packed red blood cells was significantly lower in the minimally invasive group (1.6 ± 3 U) than in the complete sternotomy group (3.7 ± 6 U; p < 0.01). Thirty late deaths (2% per patient-year) were observed in the complete sternotomy group versus zero in the minimally invasive group (p < 0.01). One patient (0.5% per patient-year) in the minimally invasive group and 12 patients (0.8% per patient-year) in the complete sternotomy group required reoperation in the follow-up period (p = 0.05). Minimally invasive David technique for patients with ascending aortic aneurysm and aortic valve insufficiency offers a good solution with low perioperative blood transfusion rate. Our midterm results show low valve-related complications and reoperation rate. However, long-term follow-up of the minimally invasive group is necessary.

Impact of Cusp Repair on Reoperation Risk After the David Procedure

We assessed whether additional cusp repair during valve-sparing aortic root replacement affects the echocardiographic mid-term results; a subgroup analysis among patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) was performed. Between June 2002 and May 2015, 157 consecutive patients underwent valve-sparing aortic root replacement with the David technique. Thirty patients (19%) had BAV. In 19 patients (12%), cusp motion or anatomic abnormalities contributed in determining aortic regurgitation requiring an additional cusp repair. Mean follow-up was 7 ± 3.4 years. The cumulative 1-, 5-, and 12-year survival rates were 98%, 94%, and 90%, respectively. Fourteen patients (9%) required aortic valve replacement during follow-up. In 2 patients the underlying cause was bacterial endocarditis. Freedom from aortic valve reoperation was 96% at 1 year, 92% at 5 years, and 89% at 12 years. Reoperation rate was significantly higher (p< 0.001) in patients who received leaflet repair compared with patients who did not, with a freedom from reoperation at 8 years of 58% versus 94%. Among patients with BAV, those who did not require cusp repair had a freedom from reoperation at 8 years of 94%, with a significant difference compared with patients who received cusp repair (p= 0.04). Cusp repair did not affect reoperation risk in patients with tricuspid aortic valve. Adjunctive cusp repair seems to affect the mid-term reoperation risk in patients with BAV and not in patients with tricuspid aortic valve. We recommend caution in using this technique in case of asymmetric BAV requiring cusp repair.

Midterm Results of Minimally Invasive Approach in David Procedure

Objectives: The David technique may provide an alternative to conduit implantation in patients with aneurysm of the ascending aorta and aortic valve insufficiency. Minimally invasive approach in valve surgery becomes more and more popular.

Long-term results of the David Procedure in patients with acute type A aortic dissection

IntroductionThe David Procedure may provide an attractive alternative to aortic root replacement in patients with aortic valve insufficiency (AI) even in the emergency setting of an acute type A aortic dissection (AAD). MethodsFrom 1996 to 2011 the David Procedure was performed in 23 patients with AAD in our department. Patients' mean age was 49 ± 15 years and 70% (n = 16) were male. Concomitant hemiarch replacement was performed in 19 patients while the remaining 4 patients underwent full arch replacement. Additional leaflet prolapse was corrected by plication in 5 cases. A modification of the classic David technique was performed by creating a pseudosinus in 6 patients (26%) and a neosinus in 9 patients (39%). Mean follow up was 7.7 ± 3 years. ResultsThirty-day mortality was zero. There were 4 late deaths (17%). One patient suffered a perioperative neurologic event (4%). One further patient suffered a late stroke during follow up (0.6%/pt-yr). Three patients (1.7%/pt-yr) required aortic valve reoperation during follow up: in 2 cases leaflet perforation was observed, and one patient had to undergo valve replacement because of endocarditis with severe AI. There were two cases of bleeding events (1.1%/pt-yr) at follow up. The linearized rate for recurrent AI≥2° was 1.1%/pt-yr. DiscussionThe David Procedure certainly provides a challenging option to treat selected young patients with AI in the presence of AAD. However, current data suggest that it is safe and feasible. ConclusionsLong-term valve-related events of the David Procedure applied in emergency cases are rare and aortic valve function remains stable for many years.

Outcomes in Aortic and Mitral Valve Replacement With Intervalvular Fibrous Body Reconstruction

Surgery for intervalvular fibrous body reconstruction in aortic and mitral valve replacement is a complex operation, although mandatory in some circumstances. The long-term result of this operation remains unknown. The objective of this study was to analyze the outcomes of this technique. A descriptive and retrospective study was carried out to analyze operative morbidity and mortality in fibrous body reconstruction with the "David technique" and to evaluate the midterm and long-term results regarding durability and survival. A total of 40 consecutive patients underwent the David technique between 1997 and 2014. The mean age was 58 ± 15 years and 62.5% were male. The indications were active endocarditis with paravalvular and fibrous body abscesses in 26 patients (group A) and massive calcification of the intervalvular fibrous body in 14 patients (group B). Mean European system for cardiac operative risk evaluation I predicted risk of mortality was 36 ± 24 and 16 ± 15, respectively. The hospital mortality rate was 15.3% in group A and 7.1% in group B. Survival rate after 1, 5, and 10 years was 65.4%, 57.7%, and 50% for group A and 92.9%, 85.7%, and 78.6% for group B. Freedom from reoperation at 1, 5, and 10 years was 92.3%, 84.6%, and 76.9% for group A and 90.9%, 90.9%, and 90.9% for group B. Mean follow-up was 53 ± 8 months. Although this complex operation is associated with high perioperative mortality, the long-term results are acceptable in patients where there are not suitable alternative procedures.

Long-term results of aortic valve resuspension in patients with aortic valve insufficiency and aortic root aneurysm

'The David technique' may provide an alternative to conduit implantation in patients with an aneurysm of the ascending aorta and aortic valve insufficiency. From 1991 to 2013, the David technique was performed in 249 consecutive patients in our department. The patient mean age was 58 ± 14 years; 71 (29%) were female and 178 (71%) male. A modification of the David technique was performed by creating a pseudosinus in 43 patients (17%) and by creating a neosinus in 123 patients (49%). The mean follow-up was 6 ± 4.5 years. There were six in-hospital (2.4%) and 30 late deaths (2.4%/patient-year). Cardiac-related events were the cause of death in three patients. The Kaplan-Meier estimate for 10 years survival was 77%. Four patients had perioperative neurological events, and only eight neurological events occurred during follow-up (0.6%/patient-year). Ten patients (0.8%/patient-year) required aortic valve replacement; one because of combined aortic valve stenosis and insufficiency and nine because of severe aortic valve insufficiency as a result of leaflet prolapse (n = 3), leaflet perforation (n = 1), abridgement of the right coronary leaflet (n = 1) and because of endocarditis (n = 4). Three cases of bleeding were observed (0.24%/patient-year). Freedom from reoperation or aortic valve insufficiency ≥2° was 80% at 10 years. Aortic valve sparing to treat patients with an ascending aortic aneurysm with aortic valve insufficiency is a durable procedure. Aortic valve function remains stable for many years. Valve-related complications are rare, and the rate of reoperations is not increased in comparison to conduit root replacement.

Three-year results from the surgical treatment of diseases of the aortic valve and aortic root

PURPOSE: Pathology of the aortic root and aortic valve is subjected to adult cardiac surgery and includes Stanford A aortic dissection, annuloaortic ectasia or chronic aneurysm of the ascending aorta. In such cases, Bentall-De Bono procedure is usually preferred. Aortic valve reimplantation by using Tirone David's technique presenting with the advantages of valve-sparing surgery can be performed in selected cases. MATERIAL AND METHODS: A retrospective analysis of a three-year experience with the complex surgical treatment of diseases of the aortic valve and root was carried out. During the period from January 1, 2009 to December 31, 2012, fifty-three patients with aortic valve and aortic root pathology were treated in the Division of Cardiac Surgery, St. Marina University Hospital of Varna. Bentall procedure was carried out in 37 patients (Group B). In 19 of them (51%) emergency surgery was done for acute aortic dissection of type Stanford A. The rest 18 patients underwent elective surgery for dilated ascending aorta and aortic valve dysfunction. Aortic valve-sparing surgery by David's technique for aortic aneurysm was accomplished in 16 patients (Group D). This technique was emergently applied in one patient with aortic dissection, too. Baseline data, intraoperative details, early results and complications were compared. RESULTS: Early (30-day) mortality after Bentall-De Bono procedure was 10.5% (0% after elective surgery and 21.1% after dissection repair). All the patients survived after David's procedure that proved the significant advantages of the valve-sparing surgery. CONCLUSION: The aortic valve reimplantation provides long-term results that are comparable to those after the Bentall-De Bono procedure such as high survival rates, low incidence rate of endocarditis, and slightly higher risk of reinterventions. There is no need of life-long anticoagulation that improves patient's quality of life. Scripta Scientifica Medica 2013; 45(4): 50-55.

Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre experience with 548 patients

The proper treatment of aneurysms of the ascending aorta is still under debate. Here, we describe the early and late outcomes after composite replacement (CR), supracommissural aortic replacement (SCR) and aortic valve-sparing (AVS) operations. Five hundred and fourty-eight patients were operated on for ascending aortic aneurysm from 1994 until 2011. Two hundred and ninety-eight (54%) patients had CR, 154 (28%) underwent SCR, 96 (18%) received AVS using David's technique [83 (15%); after October 2006] and 13 (3%) using Yacoub's technique. The average size of the aneurysms was 5.8 ± 1.3 cm and differed between groups (P < 0.001). Patients in the SCR group were older (P < 0.001), and male gender was less frequent in the Yacoub group (P = 0.004). Marfan's syndrome was present more often in the AVS group (P < 0.001). Times for operation, extracorporeal circulation and aortic cross-clamping differed significantly (P < 0.001). In the SCR group, 40% of patients additionally underwent aortic valve replacement. Rethoracotomy for bleeding was required in 33 patients. Overall, 30-day mortality was 4.8% and did not differ between groups (SCR = 7.2%, CR = 4.8%, David's technique = 0% and Yacoub's technique = 8.3%; P = 0.12). Six patients experienced cerebral accidents. The follow-up was complete for 93%, and mean follow-up time was 3.9 ± 3.9 (0-17.8) years. Kaplan-Meier analysis revealed a significantly reduced long-term survival for women (log-rank P = 0.0052). Reoperation on the aortic root was necessary in only 6 patients from the Yacoub and SCR groups. No aortic dissection occurred. By uni- or multivariate regression analysis, age and preoperative creatinine were risk factors for 30-day mortality, and age, gender, creatinine, New York Heart Association class and chronic obstructive pulmonary disease, for long-term survival. All four applied techniques result in low mortality and low reoperation rate and prevent aortic dissection. The David procedure yields excellent mid-term results.

Aortic valve-sparing operations in aortic root aneurysms: remodeling or reimplantation?

A best evidence topic was written according to a structured protocol. The question addressed was whether the reimplantation (David) technique or the remodeling (Yacoub) technique provides the optimum event free survival in patients with an aortic root aneurysm suitable for an aortic valve-sparing operation. In total, 392 papers were found using the reported search criteria, of which 14 papers provided the best evidence to answer the clinical question. A total of 1338 patients (Yacoub technique in 606 and David technique in 732) from 13 centres were included. In most series, cardiopulmonary bypass time and aortic cross-clamp time were longer for the David technique compared to the Yacoub technique. Early mortality was comparable between the two techniques (0-6.9% for the Yacoub technique and 0-6% for the David technique). There is a tendency for a higher freedom from significant long-term aortic insufficiency in the David group than the Yacoub group, which does not necessarily result in a higher reoperation rate in the Yacoub group. In the largest series reported, freedom from a moderate-to-severe aortic insufficiency at 12 years was 82.6 ± 6.2% in the Yacoub and 91.0 ± 3.8% in the David group (P=0.035). Freedom from reoperation at the same time point was 90.4 ± 4.7% in the Yacoub group and 97.4 ± 2.2% in the David group (P=0.09). In another series, freedom from reoperation at a follow-up time of about four years was 89 ± 4% in the Yacoub group and 98 ± 2% in the David group. Although some authors merely preferred the Yacoub technique for a bicuspid aortic valve, the accumulated evidence in the current review indicates comparable results for both techniques in a bicuspid aortic valve. Current evidence is in favour of the David rather than the Yacoub technique in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity. Careful selection of patients for each technique and successful restoration of normal cusp geometry are the keys to success in aortic valve-sparing operations.

Long-Term Results and Cusp Dynamics After Aortic Valve Resuspension for Aortic Root Aneurysms

This study reports our 10-year experience with the David technique and technical modifications to create neosinuses. From January 1996 to February 2009, the David procedure was performed in 151 consecutive patients in our department. Mean age was 59 ± 13 years (range, 22 to 78 years). All patients had ascending aortic aneurysm (mean diameter, 6.0 ± 1.1 cm); 59 patients had additional arch aneurysm. Fifty-four patients underwent the standard David procedure, with a pseudosinus created in 42 patients (28%) and neosinuses in 55 patients (36%) by plicating the base and sinotubular junction of the tube graft. Patients were followed up prospectively and had echocardiography studies before discharge and at follow-up. Mean follow-up was 5 years (584 patient-years). There were 6 in-hospital and 16 late deaths. Reexploration for bleeding was necessary in 27 patients (17%). Three patients had perioperative neurologic events, and 2 patients experienced them during follow-up. Five patients required late aortic valve replacement. Cardiovascular events were the cause of late death in 6 patients. Valve gradients were low, with only 2 patients having significant valve incompetence remaining. Echocardiography results showed a more physiologic, reduced velocity of cusp movement in the neosinus group compared with the conventional technique. Aortic valve resuspension is a durable procedure. Only 4.8% experienced a relevant valve dysfunction. Other valve-related complications were minimal, with three observed neurologic events and one endocarditis. Creation of the neosinus lead to more physiologic leaflet dynamics and facilitated geometric adaptation.

Modification of the David Procedure for Reconstruction of Incompetent Bicuspid Aortic Valves

The David procedure was described primarily to treat tricuspid valves. The asymmetry of the bicuspid root asks for modifications to achieve a competent bicuspid valve. The most common feature of the bicuspid valve is the presence of left and right coronary rudimentary cusps. In this case usually the base of the noncoronary cusp is displaced toward the left ventricular outflow tract. The uneven plane of this type of bicuspid aortic annulus has to be compensated for when a rigid prosthesis is wrapped around the aortic root. We describe the modification of the David technique in 14 patients who underwent a valve-sparing aortic root replacement in presence of a bicuspid valve. This technique increases the coaptation surface and provides reliable early and mid-term competence of the reconstructed bicuspid aortic valves.