Valve-sparing aortic root replacement

Valve-sparing aortic root replacement
Other namesDavid procedure
SpecialtyCardiology, cardiothoracic surgery

Valve-sparing aortic root replacement (also known as the David procedure) is a cardiac surgery procedure which is used to treat Aortic aneurysms and to prevent Aortic dissection.[1] It involves replacement of the aortic root without replacement of the aortic valve. Two similar procedures were developed, one by Sir Magdi Yacoub,[2] and another by Tirone David.[3][4]

Techniques

The valve-sparing aortic root replacement allows for direct narrowing of enlarged aortas, which change the fluid dynamics of outbound blood from the heart, while preserving the natural tissues of the aortic valve, which means the patient does not have to rely on anticoagulants. Common features of both techniques of the replacement process are the clamping of the aorta and the use of a length of Dacron tube (also known as an "aortic graft"), typically 5 cm, to constrict the aortic root to the normal diameter, while the patient is cooled to 20°C and placed on life support. The procedure typically takes 4 to 6 hours in healthy patients.[1][5]

Re-modeling technique

Established by Sir Magdi Yacoub in the mid-1990s, the process involves cutting the aorta superior of (slightly downstream of) the aortic valve and attaching the tube, one end of which has been shaped into a three-lobed wavy ring, directly to the commissures connecting the aortic valve to the aortic wall. In other words, the "sinotubular junction" holding the aortic valve in place is reformed with the tube flush with the outermost valve tissue, and extending between the valve's cusps.[6][7]

Re-implantation technique

Established by Tirone E. David and Christopher Feindel at the Toronto General Hospital in 2007,[8] this technique differs in the shape of the Dacron tube's end, which here is a ring with a flat edge, and its location, with the sinotubular junction "inserted" into the tube. In other words, the tube acts like a "corset" on the outside of the wall surrounding the aortic valve, though the tube's attachment points are the same as in the Yacoub method.[9][10][11]

Comparison with alternative procedures

Valve-sparing aortic root replacement (David procedure) is one of several surgical options for treating aortic root aneurysms and preventing aortic dissection. The choice of procedure depends on the patient's anatomy, the presence of valve disease, and surgeon expertise.

David procedure vs. PEARS procedure

The Personalized External Aortic Root Support (PEARS procedure) is a less invasive alternative to the David procedure:

  • Approach: PEARS uses an external, custom-made mesh (ExoVasc®) to reinforce the aortic root without removing aneurysmal tissue, while the David procedure involves internal replacement of the aortic root with a synthetic graft.[12][13]
  • Invasiveness: PEARS is typically performed on a beating heart without cardiopulmonary bypass, resulting in a shorter procedure time (~2 hours) compared to the David procedure (4–6 hours).[14][15]
  • Indications: PEARS is often used for early-stage aortic root dilation, while the David procedure is reserved for more advanced aneurysms or when the aorta reaches a critical size for replacement.[13][14]
  • Tissue Preservation: Both procedures preserve the native aortic valve, but PEARS retains all native aortic tissue, whereas the David procedure excises the aneurysmal root.[12][16]
  • Recovery: PEARS generally results in faster recovery and shorter hospital stays, but long-term outcomes are still under investigation, whereas the David procedure has well-established long-term results.[15][14]
  • Limitations: PEARS is not suitable for very large aneurysms (typically >50 mm), and patients may require further surgery if the aorta continues to dilate.[12]

David procedure vs. Bentall procedure

The Bentall procedure involves replacement of the aortic root and valve with a composite graft (mechanical or bioprosthetic valve sewn into a Dacron tube).[17]

  • Valve Preservation: Unlike the David procedure, the Bentall procedure replaces the aortic valve, requiring lifelong anticoagulation if a mechanical valve is used.
  • Indications: The Bentall procedure is typically chosen when the aortic valve is diseased or cannot be preserved, or in cases of acute aortic dissection.[17]
  • Outcomes: Both procedures have excellent long-term survival, but the David procedure avoids the risks and lifestyle restrictions associated with mechanical valves.[18]

David procedure vs. Yacoub procedure

The Yacoub procedure (remodeling technique) is another valve-sparing option, differing from the David procedure (reimplantation technique) in the method of graft attachment:

  • Technique: The Yacoub procedure reshapes the sinotubular junction with a Dacron graft shaped into a three-lobed ring, while the David procedure reimplants the valve inside a straight Dacron tube.[19]
  • Valve Dynamics: The Yacoub procedure may better preserve native valve dynamics, but the David procedure is associated with lower rates of late valve dysfunction.[18][20]

David procedure vs. Ross procedure

The Ross procedure involves replacing the aortic valve with the patient's own pulmonary valve (autograft) and replacing the pulmonary valve with a homograft.

  • Indications: The Ross procedure is often used in children or young adults, as the autograft can grow with the patient and does not require anticoagulation.
  • Complexity: The Ross procedure is more complex and is typically reserved for specific cases, such as young patients with aortic valve disease and a healthy pulmonary valve.[21]


Results

A 2023 literature review of David method patient outcomes after 2010 found that the chances of complications such as endocarditis and stroke, were reduced to 0.3%, while survival rates were 99% within a year and 89% within a decade afterward. The most common reason for follow-up (typically needed in 5 years) was minor chest bleeding, reported by 5.4% of patients.[22]

See also

References

  1. ^ a b "The Modified David's Reimplantation Procedure". clevelandclinic.org. Retrieved 15 July 2014.
  2. ^ Marfan Syndrome: A Primer For Clinicians And Scientists. Peter Nicholas Robinson, Maurice Godfrey eds. Chapter 5: Duke E. Cameron and Vincent L. Gott. Surgical Management of the Marfan Patient at The Johns Hopkins Hospital.
  3. ^ David, TE; David, CM; Ouzounian, M; Feindel, CM; Lafreniere-Roula, M (March 2021). "A progress report on reimplantation of the aortic valve". The Journal of Thoracic and Cardiovascular Surgery. 161 (3): 890–899.e1. doi:10.1016/j.jtcvs.2020.07.121. PMID 33008570. S2CID 222170984.
  4. ^ Sef, D; Bahrami, T; Raja, SG; Klokocovnik, T (June 2022). "Current trends in minimally invasive valve-sparing aortic root replacement-Best available evidence". Journal of Cardiac Surgery. 37 (6): 1684–1690. doi:10.1111/jocs.16453. PMID 35348237. S2CID 247777604.
  5. ^ Tooze, Adam; Abadi, Cam (March 6, 2024). "Adam's Upcoming Heart Surgery". YouTube. Foreign Policy. Retrieved December 30, 2024.
  6. ^ Yacoub, Magdi (1996). "Valve-Conserving Operation for Aortic Root Aneurysm or Dissection". Operative Techniques in Cardiac and Thoracic Surgery. 1 (1). Elsevier BV: 57–67. doi:10.1016/s1085-5637(07)70081-5. ISSN 1085-5637.
  7. ^ Yacoub, Magdi H.; Afifi, Ahmed; Hosny, Hatem; Nagy, Mohamed; Shehata, Nairouz; Gamrah, Mazen Abou; El Sawy, Amr; Simry, Walid; Mahgoub, Ahmed; Francis, Nadine; El Nashar, Hussam; Tseng, Yuan-Tsan; Romeih, Soha; Aguib, Heba (2021). "A New Technique for Shaping the Aortic Sinuses and Conserving Dynamism in the Remodeling Operation". The Annals of Thoracic Surgery. 112 (4): 1218–1226. doi:10.1016/j.athoracsur.2020.10.036. PMID 33253669.
  8. ^ "Dr. Tirone David: Looking back on a long, successful career". University Health Network Canada. 3 December 2010. Retrieved 27 Jun 2022.
  9. ^ David T, Feindel C (1992). "An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta". J Thorac Cardiovasc Surg. 103 (4): 617–21, discussion 622. doi:10.1016/S0022-5223(19)34942-6. PMID 1532219.
  10. ^ "Valve Sparing Aortic Root Replacement (David Procedure)". Columbia Surgery. November 9, 2023. Retrieved December 30, 2024.
  11. ^ Doty, Donald B; Arcidi, Joseph M (2000). "Methods for graft size selection in aortic valve-sparing operations". The Annals of Thoracic Surgery. 69 (2). Elsevier BV: 648–650. doi:10.1016/s0003-4975(99)01481-2. ISSN 0003-4975. PMID 10735728.
  12. ^ a b c "It's Topic Tuesday". Aortic Hope. 9 April 2024. Retrieved 21 August 2025.
  13. ^ a b Pepper, John; Golesworthy, Tal (7 November 2020). "PEARS procedure and the difficulty to provide evidence for its benefits". European Heart Journal. 41 (42): 4086. doi:10.1093/eurheartj/ehaa596.
  14. ^ a b c Mastrobuoni, Stefano; Govers, Pascal J.; Veen, Kevin M. (1 June 2023). "Matched comparison between external aortic root support and valve-sparing root replacement". Heart. 109 (11): 832. doi:10.1136/heartjnl-2022-321992.
  15. ^ a b "Personalised external aortic root support (PEARS)". Guy's and St Thomas' Specialist Care. 21 November 2024. Retrieved 21 August 2025.
  16. ^ Pepper, John (13 July 2024). "Personalized external aortic root support (PEARS): A narrative review". The Journal of Thoracic and Cardiovascular Surgery. doi:10.1016/j.jtcvs.2024.06.016.
  17. ^ a b Bentall, H.; De Bono, A. (1968). "A technique for complete replacement of the ascending aorta". Thorax. 23: 338–339. PMID 5669099.
  18. ^ a b David, TE; David, CM; Ouzounian, M; Feindel, CM; Lafreniere-Roula, M (March 2021). "A progress report on reimplantation of the aortic valve". The Journal of Thoracic and Cardiovascular Surgery. 161 (3): 890–899.e1. doi:10.1016/j.jtcvs.2020.07.121. PMID 33008570.
  19. ^ Yacoub, Magdi (1996). "Valve-Conserving Operation for Aortic Root Aneurysm or Dissection". Operative Techniques in Cardiac and Thoracic Surgery. 1 (1). Elsevier BV: 57–67. doi:10.1016/s1085-5637(07)70081-5. ISSN 1085-5637.
  20. ^ Yacoub, Magdi H.; Afifi, Ahmed; Hosny, Hatem (2021). "A New Technique for Shaping the Aortic Sinuses and Conserving Dynamism in the Remodeling Operation". The Annals of Thoracic Surgery. 112 (4): 1218–1226. doi:10.1016/j.athoracsur.2020.10.036. PMID 33253669.
  21. ^ Ross, Donald N. (1967). "Replacement of aortic and mitral valves with a pulmonary autograft". The Lancet. 2 (7785): 956–958. PMID 4164933.
  22. ^ Mastrobuoni, Stefano; Govers, Pascal J.; Veen, Kevin M.; Jahanyar, Jama; Saane, Silke van; Segreto, Antonio; Zanella, Luca; Kerchove, Laurent de; Takkenberg, Johanna J. M.; Arabkhani, Bardia (2023). "Valve-sparing aortic root replacement using the reimplantation (David) technique: a systematic review and meta-analysis on survival and clinical outcome". Annals of Cardiothoracic Surgery. 12 (3): 149–158. doi:10.21037/acs-2023-avs1-0038. PMC 10248907. PMID 37304702.
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