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Ann Thorac Surg 2010;89:1443-1447. doi:10.1016/j.athoracsur.2010.01.058
© 2010 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

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

Lars G. Svensson, MD, PhDa,b,*, Maxwell Cooperb, Lillian H. Batizy, MSc, Edward R. Nowicki, MD, MSb

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.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
The David reimplantation procedure is the preferred method of preserving tricuspid aortic valves during aortic root replacement [1–27]. Several modifications have been proposed, however, to simplify the operation and make it more predictable; namely, more science than art. Previously, we recommended a simplified David reimplantation procedure that reduced the anulus to a more normal size for the patient's body surface area (BSA) and created a new sinotubular junction and new coronary sinuses to accommodate the aortic valve cusps [10]. It was our conviction that these measures would result in a more durable preservation of the aortic valve free of residual aortic regurgitation (AR), with minimal aortic anulus-left ventricular outflow tract (LVOT) gradient.

The purpose of this study of an expanded series of patients undergoing a modified David reimplantation technique was to focus on the valve reimplantation aspect of this operation and to report the following results: (1) postoperative residual AR; (2) LVOT gradient; and (3) midterm valve-related reoperation.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Of 234 patients undergoing David reimplantation, or some modification thereof, from January 1, 2002 to June 1, 2008, 129 formed a single-surgeon series for the evaluation of midterm results. Data from supplemental review of medical records was approved for research by the Institutional Review Board, with patient consent waived. Patient characteristics and operative details are presented in Table 1. Sixty-one patients had Marfan syndrome (47%). Mean BSA was 2.1 ± 0.27 m2, and mean predicted normal size of the aortic anulus-LVOT was 23 ± 1.4 mm. The Z value, defined as the number of standard deviations by which the intended diameter of the repaired anulus (Hegar size, mm) deviated from mean normal LVOT diameter (mm) for a patient with that BSA, was calculated and is shown in Figure 1.


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  		Table 1 Patient Characteristics, Procedures, and Outcomes
 

Figure 1
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  		Fig 1. Cumulative distribution of Z value of intended left ventricular outflow tract diameter.

 
Preoperative in-house echocardiographic records were available in 116 patients and postoperative predischarge echocardiographic records in 101 patients (Table 1). We were particularly interested in postoperative LVOT gradients because size had been reduced in most patients.

Surgical Indications and Technique
Indications for surgery were combinations of symptomatic AR with or without left ventricular dysfunction, and root and ascending aortic dilatation (cross-sectional aortic area to height ratio exceeding 10) [28, 29].

Modifications simplifying this operation have been previously described in detail [10]. Briefly, both coronary artery buttons were mobilized and the LVOT-aortic junction dissected out to below the aortic valve anulus. A 30-mm polyester tube graft was selected for implantation unless the patient's BSA exceeded 2.5 m2, in which case a 32-mm graft was used. If BSA was less than 1.5 m2 and the cusp height small, a 28-mm graft was chosen. Nine to ten pledgeted valve sutures were placed in the LVOT, from inside out, and passed through the outer graft. These were then tied down around a Hegar dilator, selected based on patient BSA. Thus, for males with a BSA of 2.5 m2, a 23-mm Hegar was chosen, for 2.0 m2 a 21-mm Hegar, and for 1.5 m2 a 19-mm Hegar. For females, these were reduced by one size; eg, for a BSA of 2.0 m2, a 19-mm Hegar was used. The valve was then reimplanted with the sutures at the apices of the commissures placed 4 to 5 mm apart, so that when tying them down, a neo-sinotubular junction was created. The coronary buttons were then reattached and the distal anastomosis completed. Cusp repair was performed in 55 patients (43%) to correct redundant or prolapsing cusps.

Statistics
Continuous variables are summarized by mean ± standard deviation and categoric variables by frequencies and percentages. Correlation between Z value for intended LVOT and postoperative predischarge mean LVOT gradient was analyzed (Pearson correlation coefficient). Unadjusted survival was determined by the Kaplan-Meier method.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
No patient had intraoperative or in-hospital abandonment or reversal of the repair. No fistulae into surrounding chambers, ventricular septal defects, or anterior mitral valve perforations were documented. There were no postoperative deaths or strokes; however, 2 patients suffered transient ischemic attacks. Of 101 patients, 99 (98%) had 1+ or less AR postoperatively, and none had greater than 2+ AR (Table 1). Of 94 patients with both preoperative and postoperative data, 24 (26%) remained without AR and 66 (70%) had improvement in AR; only 4 (2%) had a slight increase in AR after the procedure (Table 2). Mean postoperative gradient was 9.0 ± 3.5 mm Hg. There was no correlation between Z value of intended LVOT diameter and mean gradient (Pearson r = –0.03, p = 0.8; Fig 2). Patients with residual regurgitation or gradients were treated medically as indicated without further surgical intervention, except as noted in Table 3.


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  		Table 2 Aortic Valve Regurgitation Before and After David Procedure
 

Figure 2
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  		Fig 2. Scatter plot of Z value of intended left ventricular outflow tract (LVOT) diameter and postoperative LVOT mean gradient.

 

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  		Table 3 Reoperations After Discharge
 
Postoperative valve-related reoperations are listed in Table 3 and illustrated in Figure 3. All patients undergoing reoperation had aortic valve replacement, three related to endocarditis-inflammation. One patient developed an infected toenail after swimming in the sea in South America, which resulted in endocarditis that was treated with an allograft, a second patient was treated for presumed endocarditis and fevers and underwent reoperation for scarred valve leaflets, and a third had Crohn disease with a pelvic abscess and colostomy, and the scarred down valve leaflets and inflamed root were presumed to be related to endocarditis. In the remaining patient, the anulus below the left main coronary ostium may have slipped below the graft, allowing prolapse of the left cusp and AR. Survival was 99% at 6 years, with one late postoperative death from alcoholic cardiomyopathy and sepsis (Fig 4).


Figure 3
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  		Fig 3. Aortic valve-related reoperation. Open circles represent reoperations, vertical bars are 68% confidence limits, and numbers in parentheses are patients remaining at risk.

 

Figure 4
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  		Fig 4. Unadjusted survival. Numbers in parentheses are patients remaining at risk.

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
This study demonstrates that the David reimplantation procedure can be simplified while maintaining normal valve function, with minimal postoperative AR and low LVOT gradient.

As the David reimplantation procedure has evolved, various methods have been employed to preserve and improve valve function. In our series, the near absence of AR after operation, low LVOT gradient, and low prevalence of valve-related reoperation testify to the success of this evolutionary process. Experience with cusp repair in isolated aortic valve repair has allowed us to incorporate this procedural component in 43% of patients undergoing reimplantation to further improve results.

Critical to success is ensuring that the entire valve is well seated within the tube graft, as demonstrated by Pethig and colleagues [13] and Kallenbach and colleagues [22]. It is also noteworthy that the tube graft must be large enough to accommodate the cusps. In the experience of David and colleagues [5, 6, 11, 19, 20, 23], most grafts have been 30 mm in diameter. The higher failure rate reported by Burkhart and colleagues [30] may have been due to use of smaller diameter grafts. The trend by some surgeons is to use grafts with preformed "sinuses" to accommodate the cusps [12, 15, 20]. We have generally not used this graft because of the native variability of cusps and the height at which the commissures have to be attached. Whether or not recreating a new neo-sinotubular junction is important is unclear, but may help in improving cusp opposition. The data from Miller [16] and the Stanford groups [21, 24, 25] suggest that recreating a "normal" morphologic root and sinuses is important for laminar flow and proper valve function.

Our data reveal that the mean intended LVOT (anular) diameter by Hegar dilator is 1 standard deviation below normal for our patients. We originally undersized the intended LVOT because size in normalized tables was based on aortic allograft sizes adjusted for BSA [10]. It was believed that the ex vivo size was larger than the in vivo size because of the relaxation of postmortem tissues. This study thus confirms that slightly smaller LVOT diameter (2 mm below a table size) is associated with only a minimal gradient.

Another reason for downsizing the anulus was a belief that a smaller valve is more likely to have better durability, allowing for some stretching over time. It was not possible to measure anular diameter after repair in all cases by echocardiography because of the surrounding graft. However, in those patients for whom it could be measured, anular diameter remained at Hegar size for that patient. We believe that use of a Hegar dilator within the anulus when tying down the sutures maintains adequate LVOT diameter, preventing excessive gradient.

In conclusion, this study demonstrates that a simplified David technique results in good aortic valve function with minimal gradients. The midterm results are encouraging, with only four failures (3%). Long-term follow-up will be required in patients with this operative approach, although we have obtained 94% freedom from reoperation at 9 years in our total experience with our larger series of patients undergoing traditional David reimplantation.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR JOHN S. IKONOMIDIS (Charleston, SC): That was a really great talk and I enjoyed your review of your series. The modifications of the T. David operation, the reimplantation operation, include use of a larger graft when the root is reconstructed in order to recapitulate sinuses. I noticed that with your subanular pledgeted suture line you don't actually plicate the graft first before you insert it, but you rely just on the sutures themselves to plicate the graft. Do you have any concerns about late failures with that?

DR SVENSSON: That is a good question. I think what happens is when you plicate around the Hegars, it clearly reduced to the size of the Hegars, and we have seen that on the echo, and if you try and put the Hegars back in again, it is very difficult to do that. As far as does that affect durability, I don't think so, because the stress is taken by the polyester graft and that is not going to stretch over time.

DR IKONOMIDIS: Next question. You used a 30 mm graft in all patients?

DR SVENSSON: The majority of patients we use a 30. If it is a large male with a body surface area over 2.5, we will use a 32 mm. If it is a young, small female with a body surface area of less than 1.5, I might go to a 28. But I think, as you basically imply and pointed out, it is critical to have large area of a root for the leaflets to be accommodated so they don't bang up against the polyester, and I think that was one of the reasons there have been some reports of early failures with the David reimplantation operation.

DR IKONOMIDIS: The next question is, what is your approach to the neo-sinotubular junction? How do you remodel that with this repair?

DR SVENSSON: The way we have done that is that we space the sutures approximately 4 to 5 mm apart at the commissures. What that does in effect is plicate once again at the neo-sinotubular junction area and that reduces the circumference. Now, I think the Stanford data, particularly Craig Miller's work, clearly shows that that probably does result in better flow dynamics across the aortic valve and closure of the leaflets. Whether it is going to affect long-term durability, I am not sure. But if we are trying to replicate as much as possible the normal anatomy, I think it is useful to do.

DR IKONOMIDIS: The last thing I would like to pose to you is just a basic patient question. I noticed that 40% of the patients in your series had Marfan's syndrome. One thing that I have encountered operating on these patients is that when you take a young patient with Marfan's syndrome and a 6 to 6.5 cm aortic root to surgery, and reduce the aortic root down to 3 cm as you would with a 30 or 32 mm graft, upon suturing the valve inside, you notice that now the valve leaflets are redundant and will tend to prolapse past the anulus, which we know is a predictor of failure. What is your approach to those patients? How do you restore the coaptation of these leaflets and bring the bellies of the valves up to the level of the anulus?

DR SVENSSON: There are two things that are important. One is that when you do the reimplantation the height of the commissures is adequate to take some of the body out of the leaflets. That usually means a fairly high implantation. And the second is once I have implanted the valve, I will look at all three leaflets, see if they are symmetrical, and look at my area of apposition. If I then still have some prolapse, my first choice is to do what is a modified Trussler stitch, namely a figure-of-eight suture on the leaflet that is prolapsing. If that still is not sufficient and if I have good strength in the leaflets, then I will do a mid-leaflet placation. With that combination you can usually get a valve to function very well.

I have a couple of times used Tirone David's technique of a running suture along the edge of the leaflet, however, and in particular, as you mentioned, in Marfan patients, the leaflets are very thin walled and fragile, and thus in those patients I am somewhat reluctant to do a running suture because I think long term that may pose a problem.

DR JASON SPERLING (Ridgewood, NJ): I very much enjoyed the presentation. Thanks, Dr Svensson. Two questions. Number one, I didn't see how you were sizing the aortic anulus, the actual ventriculo-aortic junction. I find that somewhat difficult to do by transesophageal echo. We seem to have good accuracy using ECG-gated CT [electrocardiographic-gated computed tomographic] angiograms, and that may influence selection of the appropriate size for the Hegar. I noticed in your presentation with greater than 100 patients that most of the Hegars that you used were 19, 21, 23. In my own much smaller experience, our native aortic anulus sizes oftentimes are 26, 28, 30, or higher. So, number one, I wanted to know if you are routinely undersizing the anulus and, number two, if you have any rules on how much you can undersize an anulus to your Hegar if you were attempting to accomplish a reduction anuloplasty to correct some aortic insufficiency?

DR SVENSSON: What I didn't really go into much, other than mentioning our Z scores, is that we downsized by one standard deviation from the normalized diameter of the anulus.

DR SPERLING: So it is always undersized?

DR SVENSSON: Basically it is undersized by one standard deviation. So, for example, a 2.0 m2 male I will use a size 21 Hegar. If it is a 2.5 m2, I will use a 23 mm. Now, for females I will downsize by one more size. My reasoning being that if you make it as small as possible as can be tolerated, and that is why we looked at the gradient pressures, you are probably going to have better long-term durability in the sense that you have now reduced the anulus to a smaller size that is reasonable without causing severe gradients.

So, although we measured the anuli on echo, the actual selection of Hegars size is entirely dependent on the patient's body surface area.

DR SPERLING: So is there sometimes quite a large discrepancy between your calculated target for them based on their body surface area and their actual anulus size?

DR SVENSSON: Yes, and that is why the plication can be quite marked in these patients, particularly in the Marfan patients. Some of those patients will have quite a big left ventricular outflow tract, but you downsize it on the basis of the body surface area.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Svensson LG, Blackstone EH, Cosgrove 3rd DM. Surgical options in young adults with aortic valve disease Curr Probl Cardiol 2003;28:417-480.[Medline]
  2. Miller DC. Valve-sparing aortic root replacement in patients with the Marfan syndrome J Thorac Cardiovasc Surg 2003;125:773-778.[Free Full Text]
  3. Karck M, Kallenbach K, Hagl C, Rhein C, Leyh R, Haverich A. Aortic root surgery in Marfan syndrome: comparison of aortic valve-sparing reimplantation versus composite grafting J Thorac Cardiovasc Surg 2004;127:391-398.[Abstract/Free Full Text]
  4. Kallenbach K, Pethig K, Schwarz M, Milz A, Haverich A, Harringer W. Valve sparing aortic root reconstruction versus composite replacement—perioperative course and early complications Eur J Cardiothorac Surg 2001;20:77-81.[Abstract/Free Full Text]
  5. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta J Thorac Cardiovasc Surg 1992;103:617-621.[Abstract]
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  14. Svensson LG, Blackstone EH, Feng J, et al. Are Marfan syndrome and marfanoid patients distinguishable on long-term follow-up? Ann Thorac Surg 2007;83:1067-1074.[Abstract/Free Full Text]
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  20. Cameron DE, Alejo DE, Patel ND, et al. Aortic root replacement in 372 Marfan patients: evolution of operative repair over 30 years Ann Thorac Surg 2009;87:1344-1349.[Abstract/Free Full Text]
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  22. Kallenbach K, Baraki H, Khaladj N, et al. Aortic valve-sparing operation in Marfan syndrome: what do we know after a decade? Ann Thorac Surg 2007;83:S764-S768.[Abstract/Free Full Text]
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  25. Markl M, Draney MT, Miller DC, et al. Time-resolved three-dimensional magnetic resonance velocity mapping of aortic flow in healthy volunteers and patients after valve-sparing aortic root replacement J Thorac Cardiovasc Surg 2005;130:456-463.[Abstract/Free Full Text]
  26. Volguina IV, Miller DC, LeMaire SA, et al. Valve-sparing and valve-replacing techniques for aortic root replacement in patients with Marfan syndrome: analysis of early outcome. Aortic Valve Operative Outcomes in Marfan Patients study group. J Thorac Cardiovasc Surg 2009;137:1124-1132.[Abstract/Free Full Text]
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