CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 140 AFRICA Long-term experience of the modified David V re-implantation technique for valve-sparing aortic root replacement Sabit Sarikaya, Kaan Kirali Abstract Objective: The modified David V technique is one of the valve-sparing aortic root replacement (V-SARR) techniques, which is an alternative to traditional composite valve graft root replacement techniques. We aimed to analyse our longterm experience with the modified David V re-implantation technique for the treatment of aortic root aneurysm and significant aortic valve insufficiency. Methods: From March 2009 to November 2021 the modified David V re-implantation technique, one of the V-SARR techniques, was performed on 48 patients in our centre. The results were analysed retrospectively. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. We performed both intra-operative and post-procedural transoesophageal echocardiography on each patient. All patients were followed by means of transthoracic echocardiography. The mean follow-up period was 5.7 ± 3.1 years. Results: The mean age of this cohort was 56.3 ± 14.3 years (24–79) and the majority were men (75%). The mean aortic root diameter was 5.1 ± 0.6 cm. The mean diameter for the assending aorta was 5.4 ± 2.1 cm. The in-hospital mortality rate was 4.2% (n = 2). One patient needed aortic valve replacement in the early postoperative period. Two (4.2%) patients died in the early postoperative period and four (8.3%) died in the late postoperative period. Overall survival was 91 ± 4 and 86 ± 5% at one and five years, respectively. Aortic valve insufficiancy was at moderate levels postoperatively. Freedom from moderate to severe residual aortic insufficiency was 89.6% at 10 years. None of the patients needed late re-operation of the aortic valve postoperatively. Freedom from valve re-operation was 100% at the end of the follow up. Conclusions: Our study shows that the David V technique is associated with excellent long-term durability, a remarkably low rate of valve-related complications, and it protects the re-implanted native aortic valve from a second operation. Additionally this technique could be safely implemented in patients with a bicuspid aortic valve and acute type A aortic dissection without leaflet deformity. Keywords: aortic valve-sparing root replacement, David procedure, re-implantation Submitted 5/4/23; accepted 12/4/23 Published online 31/5/23 Cardiovasc J Afr 2024; 35: 140–146 www.cvja.co.za DOI: 10.5830/CVJA-2023-018 In aortic root aneurysm surgery, if the aortic valve integrity is intact and in a good condition, valve-sparing aortic root replacement (V-SARR) is an alternative technique that is more attractive than other techniques and offers a good quality of life. However, the Bentall de Bono technique, which was first defined 50 years ago, is still the gold-standard technique.1-3 Possible problems related to a mechanical or bioprosthetic valve in the composite graft encouraged pioneers to search for alternative methods.4-6 Therefore, different techniques and modified forms have been described in the literature to protect the aortic valve. V-SARR techniques, defined in the literature over the years, are remodelling (Yacoup procedure, David III) and re-implantation techniques (David IV and David V).5-8 Recently, the David V re-implantation technique has become one of the most preferred V-SARR techniques. The same-size grafts are used in the proximal and distal positions. In the David V, a pseudo-sinus is created by narrowing the proximal graft both at the top and the bottom. In addition, a Stanford modification was described in the David V re-implantation technique. In the Stanford modification (a modified David V), a larger size graft (10–12 mm) is used in the proximal position rather than in the distal site. It is intended to create a neo-sinus by using two grafts with different sizes to mimic a natural aortic root and sinus of Valsalva.8 The neo-sinus ensures long-term durability of the transferred aortic valves.8,9 V-SARR techniques are technically challenging to perform, therefore, they require a cardiac centre and an operator with a high amount of experience with the procedure. This may be the reason why the use of the technique has remained limited.7 In our opinion, aortic root repair could be performed as commonly as mitral valve repairs, especially for modified V-SARR techniques. For this reason, we publish this case series on patients undergoing the modified David V procedure, and share our long-term experience with the procedure. Methods This retrospective cohort study with unidentified patient data was approved by the review ethics board of our hospital and a waiver of consent was obtained (approval no: 2023.02.655). Our hospital database was analysed retrospectively for patients who underwent the modified David V procedure between 2009 and 2021. Forty-eight patients were included in our study and they were operated on with only the modified David V technique. Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey Sabit Sarikaya, MD, sabitsarikaya@yahoo.com Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey Kaan Kirali, MD
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