Freedom from Aortic Valve–Related Reoperation and Long-Term Survival after the David Procedure: A Single-Center Experience in 500 Patients

Objectives: The aim of this study was to evaluate aortic valve–related reoperation and mortality rates after the David procedure.

Methods: Between 1997 and 2018, 500 patients (409 males; mean age 53 ± 15 years, range: 14–80) underwent valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically. Comparative survival analysis of an age- and gender-matched general German population was calculated. Multiple logistic regression analysis was used to identify risk factors.

Results: The follow-up was 99% complete. Cumulative follow-up time was 3,011 patient-years (mean follow-up time: 5.7 ± 3.4 years). A 30-day mortality was 1.2% (6 of 500), and late mortality was 4% (22 of 500). Overall freedom from aortic valve replacement was 95 and 90% at 5 and 10 years, respectively. In patients with tricuspid aortic valves (n = 387), freedom from reoperation was 95 and 91% at 5 and 10 years, respectively. This was comparable to patients with bicuspid aortic valves (BAVs) (n = 113) with a freedom from reoperation of 98% at 5 years (p = 0.074). Two hundred and twenty-eight patients (46%) required additional cusp repair, 97 patients (20%) presenting with a BAV morphology demonstrating a 96% freedom from reoperation at 5 years. Overall, 21 patients (4%) required reoperation with a mean interval of 11.5 ± 10.7 months. Reasons for reoperation were recurrent aortic valve regurgitation ≥ grade II (n = 11), aortic stenosis (n = 6), endocarditis (n = 3), and a ruptured central plication (n = 1).

Conclusion: The David procedure revealed excellent long-term survival independently from the valve morphology and is comparable with that of an age- and gender-matched general populations. Additional cusp repair was no linked to failure of this procedure.