Background: The aim of this study was to prove the feasibility and safety of minimally invasive
aortic valve (AV) reimplantation (David procedure) via upper ministernotomy, as well
as to assess long-term outcomes with particular regard to AV performance.
Methods: Between January 2000 and August 2023 one-hundred-twenty-two patients undergoing a
minimally invasive AV reimplantation via upper ministernotomy (median age 57 years;
21% females) were included in this retrospective, single-center study. Thirty-six
(30%) patients had bicuspid AV and aortic regurgitation (AR) >moderate was present
in sixty-two (51%). The primary endpoints were defined as peri- and early postoperative
outcomes and long-term AV performance (freedom from AV and/or aortic root-related
reoperation and from AR ≥moderate). The secondary endpoint was survival. Follow-up
was completed in 99% (median of 7.1 years; 768 patients-years).
Results: Plication of at least one cusp was necessary in 79 (65%) patients and arch surgery
in 23 (19%). Conversion to sternotomy was required in 2 (1.6%) patients. Median cardio-pulmonary
bypass aortic cross-clamp time was 174 and 133 minutes, respectively. Five patients
(4.1%) required re-exploration due to postoperative bleeding. There was no 30-day
mortality, no stroke and 1 deep sternal wound infection observed. During the follow-up
3 patients were reoperated and 8 patients were diagnosed with recurrent AR, leading
to the freedom from AV and/or aortic root-related reoperation and from AR ≥moderate
at 5 and 10 years of 98% and 96% and 97% and 87%, respectively. Eleven patients died
during the follow-up showing the survival at 5 and 10 years of 99 ± 1% and 91 ± 4%.
Conclusion: This study shows David procedure can be performed safely in minimally invasive fashion
via upper ministernotomy. However, it should be limited to the centres with high experience
in minimally invasive cardiac surgery. Additionally, precise selection and preoperative
planning, including CT angiography of patients and further investigation are warranted.
