From the Guidelines
The David procedure is a valve-sparing aortic root replacement operation that reimplants the native aortic valve into a prosthetic aortic graft, allowing patients to potentially avoid the lifelong risks and complications associated with prosthetic valves. This procedure is primarily performed on patients with aortic root aneurysms who have normal or repairable aortic valve leaflets, particularly those with connective tissue disorders like Marfan syndrome 1. The main advantage of this approach is that patients can avoid the need for lifelong anticoagulation therapy that would be required with mechanical valve replacement.
Key Points
- The David procedure involves reimplanting the native aortic valve into a prosthetic aortic graft that is attached to the left ventricular outflow tract proximally and to the ascending aorta distally 1.
- The procedure is associated with a very low surgical risk when performed by experienced surgeons in Multidisciplinary Aortic Teams 1.
- Durability of the spared native aortic valve is a potential concern, with one series showing that 7% of patients with Marfan syndrome developed at least moderate aortic regurgitation at 1 year follow-up 1.
Considerations
- The David procedure is a complex operation that requires careful patient selection and a skilled surgical team.
- Patients who undergo the David procedure can expect excellent long-term outcomes, with the potential to maintain good valve function for 10-15 years or more after surgery.
- The procedure has the advantage of avoiding the lifelong risks and complications associated with prosthetic valves, making it a desirable option for patients with aortic root aneurysms who have normal or repairable aortic valve leaflets.
From the Research
Overview of the David Procedure
The David procedure, also known as the aortic valve-sparing operation, is a surgical technique used to treat aortic root aneurysms while preserving the patient's native aortic valve 2, 3, 4, 5, 6. This approach is considered a valuable alternative to traditional valve replacement surgery, as it aims to maintain the patient's natural valve function and avoid the need for long-term anticoagulation therapy.
Key Characteristics of the David Procedure
- The David procedure involves the replacement of the aortic root with a graft, while preserving the native aortic valve 4.
- The technique can be performed using a straight tube graft (David I procedure) or a more complex graft design (David V procedure) 3, 4.
- The procedure can be performed through a traditional full sternotomy or a minimally invasive upper hemisternotomy approach 2.
- The David procedure has been shown to be effective in treating aortic root aneurysms, with excellent long-term valve function and low rates of valve-related complications 3, 4, 5.
Comparison with Other Surgical Techniques
- The David procedure has been compared to other valve-sparing techniques, such as the Yacoub technique, with similar outcomes in terms of early mortality and freedom from significant long-term aortic insufficiency 6.
- The David procedure has also been compared to bioprosthetic valve conduit root replacement, with favorable outcomes in terms of postoperative aortic insufficiency grade and intensive care unit length of stay 5.
Indications and Patient Selection
- The David procedure is indicated for patients with aortic root aneurysms who have a normal native aortic valve and are suitable for valve-sparing surgery 2, 3, 4, 5, 6.
- Patient selection is critical, and careful evaluation of the patient's valve anatomy and function is necessary to determine the best surgical approach 6.