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Original Articles: Adult Cardiac

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

^a Aorta Center, Cleveland Clinic, Cleveland, Ohio
^b Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
^c Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio

Accepted for publication January 20, 2010.

^_* Address correspondence to Dr Svensson, Aorta Center, and Marfan & Connective Tissue Disorder Clinic, 9500 Euclid Ave/Desk J4-1, Cleveland, OH 44195 (Email: svenssl{at}ccf.org).

Presented at the Fifty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 4–7, 2009.

Background: 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.

Methods: 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 m². Preoperative aortic regurgitation grade was 1+ or less in 46%, 2+ in 26%, 3+ in 24%, and 4+ in 4.3%.

Results: 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.

Conclusions: 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.

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