Valve-Sparing Aortic Root Reimplantation: Early- and Mid-Term Outcomes

Abstract

Background

Valve-sparing root replacement (VSRR) is an alternative to traditional valve-replacing root replacement. We examined early- and mid-term outcomes after VSRR.

Methods

We performed a retrospective review of a prospectively maintained aortic registry. All patients undergoing VSRR from 2005 to 2023 were included. Statistical analysis was performed in R version 4.3.1. Kaplan–Meier curves were used to describe mortality and freedom from mortality, aortic insufficiency (AI) > 1 + , and aortic valve-related reoperation.

Results

Eighty-one patients underwent VSRR, 59 (72.8%) through full sternotomy (FS) and 22 (27.2%) through upper hemisternotomy. There were no cases of AI > 1+ in the perioperative period, 1 (1.2%) stroke, and no in-hospital mortality. Mean intensive care unit and hospital stay were 3 and 7 days, respectively. Mean follow-up time was 8 years. Freedom from all-cause mortality at 1, 5, and 10 years was 100, 96.6, and 94.4%, respectively. Composite freedom from reoperation, recurrence, or mortality at 1, 5, and 10 years was 98.8, 92.1, and 87.3%, respectively.

Conclusion

With careful preoperative selection, VSRR is a durable procedure for patients with aortic root aneurysm.

Keywords

valve-sparing root reimplantation - David procedure - root aneurysm - upper - hemisternotomy

Ethical Approval Statement

The IRB Number is iRISID-2023–1860, obtained: 1/31/23.

Publication History

Received: 19 February 2024

Accepted: 25 June 2025

Article published online:
19 July 2025

• References

• 1 Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968; 23 (04) 338-339
• 2 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 (04) 617-621 , discussion 622
• 3 Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993; 105 (03) 435-438
• 4 Ouzounian M, Rao V, Manlhiot C. et al. Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation. J Am Coll Cardiol 2016; 68 (17) 1838-1847
• 5 Malaisrie SC, Kislitsina ON, Wilsbacher L. et al. Valve-sparing versus valve-replacing aortic root replacement in patients with aortic root aneurysm. J Card Surg 2022; 37 (07) 1947-1956
• 6 Esaki J, Leshnower BG, Binongo JN. et al. The David V valve-sparing root replacement provides improved survival compared with mechanical valve-conduits in the treatment of young patients with aortic root pathology. Ann Thorac Surg 2016; 102 (05) 1522-1530
• 7 David TE. Tirone on Tirone David operation and types. Gen Thorac Cardiovasc Surg 2019; 67 (01) 66-69
• 8 Miller DC. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thorac Cardiovasc Surg 2003; 125 (04) 773-778
• 9 De Paulis R, De Matteis GM, Nardi P. et al. One-year appraisal of a new aortic root conduit with sinuses of Valsalva. J Thorac Cardiovasc Surg 2002; 123 (01) 33-39
• 10 Miller DC. Rationale and results of the Stanford modification of the David V reimplantation technique for valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 2015; 149 (01) 112-114
• 11 David TE, Armstrong S, Maganti M, Colman J, Bradley TJ. Long-term results of aortic valve-sparing operations in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2009; 138 (04) 859-864 , discussion 863–864
• 12 Monsefi N, Risteski P, Miskovic A, Moritz A, Zierer A. Midterm results of a minimally invasive approach in David procedure. Thorac Cardiovasc Surg 2018; 66 (04) 301-306
• 13 Shrestha M, Kaufeld T, Shrestha P. et al. Valve-sparing David procedure via minimally invasive access does not compromise outcome. Front Cardiovasc Med 2022; 9: 966126
• 14 Shah VN, Kilcoyne MF, Buckley M, Orlov OI, Sicouri S, Plestis KA. How we perform a David procedure with an upper hemisternotomy approach. Innovations (Phila) 2021; 16 (06) 545-552
• 15 Jahanyar J, de Kerchove L, Tsai PI. et al. Patient selection for aortic valve-sparing operations. Ann Cardiothorac Surg 2023; 12 (03) 259-261
• 16 Shah VN, Orlov OI, Orlov C. et al. Minimally invasive valve-sparing aortic root reimplantation in a tricuspid aortic valve. ASVIDE 2018; 5: 671
• 17 Deas Jr DS, Lou X, Leshnower BG. et al. Fifteen years of aortic valve-sparing root replacement and impact of eccentric jets on late outcomes. Ann Thorac Surg 2021; 112 (06) 1901-1907
• 18 Manganiello S, Soquet J, Mugnier A. et al. David procedure: a 21-year experience with 300 patients. Ann Thorac Surg 2023; 115 (06) 1403-1410
• 19 David TE, Feindel CM, David CM, Manlhiot C. A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014; 148 (03) 872-879 , discussion 879–880
• 20 Beckmann E, Martens A, Krüger H. et al. Aortic valve-sparing root replacement with Tirone E. David's reimplantation technique: single-centre 25-year experience. Eur J Cardiothorac Surg 2021; 60 (03) 642-648
• 21 Tamer S, Mastrobuoni S, Lemaire G. et al. Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair. Eur J Cardiothorac Surg 2021; 59 (05) 1069-1076
• 22 de Kerchove L, Glineur D, Poncelet A. et al. Repair of aortic leaflet prolapse: a ten-year experience. Eur J Cardiothorac Surg 2008; 34 (04) 785-791
• 23 Yanagawa B, Mazine A, El-Hamamsy I. Predictors of aortic valve repair failure. Innovations (Phila) 2019; 14 (03) 199-208
• 24 Aybek T, Sotiriou M, Wöhleke T. et al. Valve opening and closing dynamics after different aortic valve-sparing operations. J Heart Valve Dis 2005; 14 (01) 114-120
• 25 De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001; 72 (02) 487-494