Is the David procedure a valve-sparing aortic root replacement?

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Last updated: October 20, 2026 • View editorial policy

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Yes, the David procedure is definitively a valve-sparing aortic root replacement (VSRR).

The David procedure is a valve-sparing aortic root replacement technique in which the native aortic valve is reimplanted into a prosthetic aortic graft, thereby preserving the patient's own valve and avoiding the need for a prosthetic valve replacement. 1

What the David Procedure Entails

The David procedure involves:

  • Reimplantation of the native aortic valve into a prosthetic aortic graft
  • The graft is attached to the left ventricular outflow tract proximally and to the ascending aorta distally
  • The coronary arteries are reimplanted into the new graft 1

This stands in contrast to the Bentall procedure (composite valved graft conduit), which replaces both the aortic root AND the aortic valve with a prosthetic valve (mechanical or bioprosthetic) and graft 1.

Key Advantages of Valve-Sparing Approach

The primary benefit is that patients can potentially avoid the lifelong risks and complications associated with prosthetic valves, including:

  • Anticoagulation requirements (with mechanical valves)
  • Structural valve deterioration (with bioprosthetic valves)
  • Thromboembolic complications
  • Bleeding risks 1

Clinical Outcomes

The David procedure demonstrates excellent results:

  • Freedom from valve reoperation: 97% at 5 years, 92.9% at 10 years, and 92.5% at 15 years 2
  • In-hospital mortality as low as 1-4% 2, 3
  • Freedom from moderate-to-severe aortic insufficiency: 84.8% at 5 years and 74.3% at 10 years 2

Important Caveats

Durability of the spared native valve is a concern—approximately 7% of patients with Marfan syndrome developed at least moderate aortic regurgitation at 1-year follow-up 1.

Predictive factors for late valve failure include:

  • Preoperative aortic insufficiency ≥ grade 2 (hazard ratio 1.782)
  • Ventriculoaortic junction ≥ 29 mm (hazard ratio 3.379) 2

These factors should guide patient selection—patients with significant preoperative AI or large annular dimensions may be better candidates for composite valve replacement rather than valve-sparing techniques.

References

2
Research

David Procedure: A 21-year Experience With 300 Patients.

The Annals of thoracic surgery, 2023

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