Valve-sparing aortic root replacement

{{expert needed|Medicine|reason=the procedure duration has only one flimsy source: the 5 hour statistic needs to be verified; also, feedback on the "other words" is needed|date=December 2024}} {{Infobox medical intervention | name = Valve-sparing aortic root replacement | synonym = David procedure | image = | caption = | alt = | pronounce = | specialty = Cardiology, cardiothoracic surgery | synonyms = | ICD10 = | ICD9 = | ICD9unlinked = | CPT = | MeshID = | LOINC = | other_codes = | MedlinePlus = | eMedicine = }} '''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.<ref name="The Modified David's Reimplantation Procedure">{{cite web|title=The Modified David's Reimplantation Procedure|url=http://my.clevelandclinic.org/heart/disorders/aorta_marfan/davidreimplantation.aspx|website=clevelandclinic.org|access-date=15 July 2014}}</ref> It involves replacement of the aortic root without replacement of the aortic valve. Two similar procedures were developed, one by Sir Magdi Yacoub,<ref>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.</ref> and another by Tirone David.<ref name="David 2022">{{cite journal |last1=David |first1=TE |last2=David |first2=CM |last3=Ouzounian |first3=M |last4=Feindel |first4=CM |last5=Lafreniere-Roula |first5=M |title=A progress report on reimplantation of the aortic valve. |journal=The Journal of Thoracic and Cardiovascular Surgery |date=March 2021 |volume=161 |issue=3 |pages=890–899.e1 |doi=10.1016/j.jtcvs.2020.07.121 |pmid=33008570|s2cid=222170984 |doi-access=free }}</ref><ref name="Sef et al 2022">{{cite journal |last1=Sef |first1=D |last2=Bahrami |first2=T |last3=Raja |first3=SG |last4=Klokocovnik |first4=T |title=Current trends in minimally invasive valve-sparing aortic root replacement-Best available evidence. |journal=Journal of Cardiac Surgery |date=June 2022 |volume=37 |issue=6 |pages=1684–1690 |doi=10.1111/jocs.16453 |pmid=35348237|s2cid=247777604 }}</ref>

==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.<ref name="The Modified David's Reimplantation Procedure"/><ref name="Tooze Abadi 2024">{{cite web | last1=Tooze|first1=Adam|last2=Abadi|first2=Cam|publisher=Foreign Policy| title=Adam's Upcoming Heart Surgery | website=YouTube | date=March 6, 2024 | url=https://www.youtube.com/watch?v=v8Psyp2WKTE | access-date=December 30, 2024}}</ref>

===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.<ref name="Yacoub July 1996">{{cite journal | last=Yacoub | first=Magdi | title=Valve-Conserving Operation for Aortic Root Aneurysm or Dissection | journal=Operative Techniques in Cardiac and Thoracic Surgery | publisher=Elsevier BV | volume=1 | issue=1 | year=1996 | issn=1085-5637 | doi=10.1016/s1085-5637(07)70081-5 | doi-access=free | pages=57–67}}</ref><ref name="Yacoub et al 2021">{{cite journal | last1=Yacoub | first1=Magdi H. | last2=Afifi | first2=Ahmed | last3=Hosny | first3=Hatem | last4=Nagy | first4=Mohamed | last5=Shehata | first5=Nairouz | last6=Gamrah | first6=Mazen Abou | last7=El Sawy | first7=Amr | last8=Simry | first8=Walid | last9=Mahgoub | first9=Ahmed | last10=Francis | first10=Nadine | last11=El Nashar | first11=Hussam | last12=Tseng | first12=Yuan-Tsan | last13=Romeih | first13=Soha | last14=Aguib | first14=Heba | title=A New Technique for Shaping the Aortic Sinuses and Conserving Dynamism in the Remodeling Operation | journal=The Annals of Thoracic Surgery | volume=112 | issue=4 | date=2021 | doi=10.1016/j.athoracsur.2020.10.036 | pages=1218–1226| pmid=33253669 }}</ref>

===Re-implantation technique=== Established by Tirone E. David and Christopher Feindel at the Toronto General Hospital in 2007,<ref>{{cite web|title=Dr. Tirone David: Looking back on a long, successful career |url=https://www.uhn.ca/corporate/News/Pages/dr_Tirone_David_Looking_long_successful_career.aspx| website=University Health Network Canada |date=3 December 2010 |access-date=27 Jun 2022}}</ref> 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.<ref name="David">{{Cite journal|vauthors=David T, Feindel C | title = An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. | journal = J Thorac Cardiovasc Surg | volume = 103 | issue = 4 | pages = 617–21; discussion 622 | year = 1992 | doi = 10.1016/S0022-5223(19)34942-6 | pmid = 1532219| doi-access = free }}</ref><ref name="Columbia 2023">{{cite web | title=Valve Sparing Aortic Root Replacement (David Procedure) | website=Columbia Surgery | date=November 9, 2023 | url=https://columbiasurgery.org/conditions-and-treatments/valve-sparing-aortic-root-replacement-david-procedure | access-date=December 30, 2024}}</ref><ref name="Doty Arcidi 2000">{{cite journal | last1=Doty | first1=Donald B | last2=Arcidi | first2=Joseph M | title=Methods for graft size selection in aortic valve-sparing operations | journal=The Annals of Thoracic Surgery | publisher=Elsevier BV | volume=69 | issue=2 | year=2000 | issn=0003-4975 | doi=10.1016/s0003-4975(99)01481-2 | pages=648–650| pmid=10735728 }}</ref>

==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.<ref name="AorticHope2024">{{cite web | title=It's Topic Tuesday | url=https://www.aortichope.org/post/it-s-topic-tuesday-115 | website=Aortic Hope | date=9 April 2024 | access-date=21 August 2025}}</ref><ref name="EurHeartJ2020">{{cite journal | last1=Pepper | first1=John | last2=Golesworthy | first2=Tal | title=PEARS procedure and the difficulty to provide evidence for its benefits | journal=European Heart Journal | volume=41 | issue=42 | pages=4086–4088 | date=7 November 2020 | doi=10.1093/eurheartj/ehaa596 }}</ref> * '''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).<ref name="Heart2023">{{cite journal | last1=Mastrobuoni | first1=Stefano | last2=Govers | first2=Pascal J. | last3=Veen | first3=Kevin M. | title=Matched comparison between external aortic root support and valve-sparing root replacement | journal=Heart | volume=109 | issue=11 | pages=832 | date=1 June 2023 | doi=10.1136/heartjnl-2022-321992 }}</ref><ref name="GSTT2024">{{cite web | title=Personalised external aortic root support (PEARS) | url=https://guysandstthomasspecialistcare.co.uk/treatments/personalised-external-aortic-root-support-pears/ | website=Guy's and St Thomas' Specialist Care | date=21 November 2024 | access-date=21 August 2025}}</ref> * '''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.<ref name="EurHeartJ2020" /><ref name="Heart2023" /> * '''Tissue Preservation:''' Both procedures preserve the native aortic valve, but PEARS retains all native aortic tissue, whereas the David procedure excises the aneurysmal root.<ref name="AorticHope2024" /><ref name="JTCVS2024">{{cite journal | last1=Pepper | first1=John | title=Personalized external aortic root support (PEARS): A narrative review | journal=The Journal of Thoracic and Cardiovascular Surgery | date=13 July 2024 | doi=10.1016/j.jtcvs.2024.06.016 | volume=169 | pages=427–435.e2 }}</ref> * '''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.<ref name="GSTT2024" /><ref name="Heart2023" /> * '''Limitations:''' PEARS is not suitable for very large aneurysms (typically >50 mm), and patients may require further surgery if the aorta continues to dilate.<ref name="AorticHope2024" />

===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).<ref name="Bentall1968">{{cite journal | last1=Bentall | first1=H. | last2=De Bono | first2=A. | title=A technique for complete replacement of the ascending aorta | journal=Thorax | volume=23 | pages=338–339 | year=1968 | pmid=5669099 }}</ref> * '''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.<ref name="Bentall1968" /> * '''Outcomes:''' Both procedures have excellent long-term survival, but the David procedure avoids the risks and lifestyle restrictions associated with mechanical valves.<ref name="David2021">{{cite journal | last1=David | first1=TE | last2=David | first2=CM | last3=Ouzounian | first3=M | last4=Feindel | first4=CM | last5=Lafreniere-Roula | first5=M | title=A progress report on reimplantation of the aortic valve | journal=The Journal of Thoracic and Cardiovascular Surgery | volume=161 | issue=3 | pages=890–899.e1 | date=March 2021 | doi=10.1016/j.jtcvs.2020.07.121 | pmid=33008570 }}</ref>

===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.<ref name="Yacoub1996">{{cite journal | last=Yacoub | first=Magdi | title=Valve-Conserving Operation for Aortic Root Aneurysm or Dissection | journal=Operative Techniques in Cardiac and Thoracic Surgery | publisher=Elsevier BV | volume=1 | issue=1 | year=1996 | issn=1085-5637 | doi=10.1016/s1085-5637(07)70081-5 | pages=57–67 }}</ref> * '''Valve Dynamics:''' The Yacoub procedure may better preserve native valve dynamics, but the David procedure is associated with lower rates of late valve dysfunction.<ref name="David2021" /><ref name="Yacoub2021">{{cite journal | last1=Yacoub | first1=Magdi H. | last2=Afifi | first2=Ahmed | last3=Hosny | first3=Hatem | title=A New Technique for Shaping the Aortic Sinuses and Conserving Dynamism in the Remodeling Operation | journal=The Annals of Thoracic Surgery | volume=112 | issue=4 | date=2021 | doi=10.1016/j.athoracsur.2020.10.036 | pages=1218–1226| pmid=33253669 }}</ref>

===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.<ref name="Ross2022">{{cite journal | last1=Ross | first1=Donald N. | title=Replacement of aortic and mitral valves with a pulmonary autograft | journal=The Lancet | volume=2 | issue=7523 | pages=956–958 | year=1967 | pmid=4167516 | doi=10.1016/s0140-6736(67)90794-5 }}</ref>

==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.<ref name="2023 meta-analysis">{{cite journal | last1=Mastrobuoni | first1=Stefano | last2=Govers | first2=Pascal J. | last3=Veen | first3=Kevin M. | last4=Jahanyar | first4=Jama | last5=Saane | first5=Silke van | last6=Segreto | first6=Antonio | last7=Zanella | first7=Luca | last8=Kerchove | first8=Laurent de | last9=Takkenberg | first9=Johanna J. M. | last10=Arabkhani | first10=Bardia | title=Valve-sparing aortic root replacement using the reimplantation (David) technique: a systematic review and meta-analysis on survival and clinical outcome | journal=Annals of Cardiothoracic Surgery | volume=12 | issue=3 | date=2023 | pmid=37304702 | pmc=10248907 | doi=10.21037/acs-2023-avs1-0038 | doi-access=free | pages=149–158}}</ref>

==References== {{Reflist}}

==External links== * [https://web.archive.org/web/20061126121925/http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/2/2003/811 Chapter 31: Aortic Valve Repair and Aortic Valve-Sparing Operations] by Tirone E. David in ''Cardiac Surgery in the Adult''

Category:Cardiac surgery