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ObjectivesAortic valve-sparing root replacement (AVSRR) is a technically demanding procedure. In experienced centers it offers excellent short- and long-term results, making the procedure an attractive alternative for aortic root replacement especially in young patients. The aim of this study was to analyze long-term results of AVSRR using the David operation in our institution over the last 25 years.MethodsThis is a single-center retrospective analysis of outcomes of David operations performed in a teaching institution not running a large AVSRR-program. Pre-, intra- and postoperative data were collected from the institutional electronic medical record system. Follow-up data were collected through direct contact of the patients and their cardiologists/primary care physicians.ResultsBetween 02/1996 and 11/2019, 131 patients underwent David operation in our institution by a total of 17 different surgeons. Median age was 48 (33–59), 18% were female. Elective surgery was performed in 89% of the cases, 11% were operated as emergency in the setting of an acute aortic dissection. Connective tissue disease was present in 24% and 26% had a bicuspid aortic valve. At hospital admission 61% had aortic regurgitation grade ≥3, 12% were in functional NYHA-class ≥III. 30-day mortality was 2%, 97% of the patients were discharged with aortic regurgitation ≤2. In 10-year follow-up, 15 (12%) patients had to be re-operated because of root-related complications. Seven patients (47%) received a transcatheter aortic valve implantation, 8 (53%) required surgical replacement of the aortic valve or a Bentall-De Bono operation. Estimated reoperation-free survival at 5 and 10 years was 93.5% ± 2.4% and 87.0% ± 3.5%, respectively. Subgroup analysis showed no differences in reoperation-free survival for patients presenting with a bicuspid valve or preoperative aortic regurgitation ≥3. However a preoperative left ventricular end diastolic diameter of ≥5.5 cm was associated with worse outcome.ConclusionDavid operations can be performed with excellent perioperative and 10-year follow-up outcomes in centers not running large AVSRR-programs.

Objectives: Aortic valve-sparing root replacement (AVSRR) is a technically demanding procedure. In experienced centers it offers excellent short- and long-term results, making the procedure an attractive alternative for aortic root replacement especially in young patients. The aim of this study was to analyze long-term results of AVSRR using the David operation in our institution over the last 25 years., Methods: This is a single-center retrospective analysis of outcomes of David operations performed in a teaching institution not running a large AVSRR-program. Pre-, intra- and postoperative data were collected from the institutional electronic medical record system. Follow-up data were collected through direct contact of the patients and their cardiologists/primary care physicians., Results: Between 02/1996 and 11/2019, 131 patients underwent David operation in our institution by a total of 17 different surgeons. Median age was 48 (33-59), 18% were female. Elective surgery was performed in 89% of the cases, 11% were operated as emergency in the setting of an acute aortic dissection. Connective tissue disease was present in 24% and 26% had a bicuspid aortic valve. At hospital admission 61% had aortic regurgitation grade ≥3, 12% were in functional NYHA-class ≥III. 30-day mortality was 2%, 97% of the patients were discharged with aortic regurgitation ≤2. In 10-year follow-up, 15 (12%) patients had to be re-operated because of root-related complications. Seven patients (47%) received a transcatheter aortic valve implantation, 8 (53%) required surgical replacement of the aortic valve or a Bentall-De Bono operation. Estimated reoperation-free survival at 5 and 10 years was 93.5% ± 2.4% and 87.0% ± 3.5%, respectively. Subgroup analysis showed no differences in reoperation-free survival for patients presenting with a bicuspid valve or preoperative aortic regurgitation ≥3. However a preoperative left ventricular end diastolic diameter of ≥5.5 cm was associated with worse outcome., Conclusion: David operations can be performed with excellent perioperative and 10-year follow-up outcomes in centers not running large AVSRR-programs., Competing Interests: The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s., (© 2023 Sromicki, Van Hemelrijck, Schmiady, Greutmann, Bonassin Tempesta, Mestres, Vogt, Carrel and Holubec.)

Reimplantation of the aortic valve is a procedure well recognized for its safety, excellent success in preserving the leaflets without a composite valve graft, and long-term durability. Unanswered questions are whether the procedure should be used for bicuspid valves and, if so, which ones, and also the role of leaflet repair. In our experience with just under 2000 aortic valve repairs, we found that use of a root procedure, particularly root reimplantation, resulted in excellent long-term durability. Just as with mitral valve repairs that include an annular ring, it appears that for aortic valve repairs, bracing the root is important. We have found that leaflet repair during a reimplantation procedure is not detrimental to long-term durability. [ABSTRACT FROM AUTHOR]

A 31-year-old woman with Marfan syndrome required aortic root repair for annuloaortic ectasia in the 16th week of her first pregnancy. Aortic root reimplantation was successfully performed with a higher-flow-rate cardiopulmonary bypass of 3.4-3.6 l/min/m at normothermia for fetal survival. During the surgery, a cardiotocography and transesophageal echo probe attached on the patient's abdomen allowed adequate monitoring of the fetal heartbeat. The postoperative course was uneventful, and a healthy baby was delivered by cesarean section at 37 weeks' gestation. [ABSTRACT FROM AUTHOR]