title: Simplified david reimplantation with reduction of anular size and creation of artificial sinuses.
abstract: BACKGROUND
  The David reimplantation procedure is the preferred method of preserving tricuspid aortic valves during aortic root replacement. We report the results of a simplified approach to the David valve-sparing root reimplantation.
  
  
  METHODS
  Of 234 patients who underwent David reimplantation or some modification thereof, 129 operated on from January 2001 to June 2008 formed a consecutive single-surgeon series for midterm evaluation. Aortic anulus-left ventricular outflow tract and proximal tube graft size were reduced over a Hegar dilator to mean normal diameter based on body surface area, in the process creating neo-sinuses to accommodate cusp opening. Sixty-one patients (47%) had Marfan syndrome. Mean body surface area was 2.1 +/- 0.27 m(2). Preoperative aortic regurgitation grade was 1+ or less in 46%, 2+ in 26%, 3+ in 24%, and 4+ in 4.3%.
  
  
  RESULTS
  Left ventricular outflow tract sizing by Hegar dilator was 17 mm in 9.5% of patients, 19 mm in 18%, 21 mm in 56%, and 23 mm in 16%. Fifty-five (43%) had concomitant cusp repair. Postoperative aortic regurgitation grade was 0 in 98%, and none of the remaining had greater than 2+ AR. Postoperative mean aortic gradient was 9.0 +/- 3.5 mm Hg. No patient had intraoperative abandonment of the repair, and there were no postoperative deaths or strokes. Five-year survival was 99%, and 4 patients (3%) required late valve replacement.
  
  
  CONCLUSIONS
  A simple modification of the David operation, reducing anular size, and creating neo-sinuses preserves the aortic valve, eliminates aortic regurgitation, avoids aortic stenosis, and has favorable midterm results.
authors.affiliation: Aorta Center, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.forename: Maxwell
authors.initials: M
authors.lastname: Cooper
authors.forename: Lillian H
authors.initials: LH
authors.lastname: Batizy
authors.forename: Edward R
authors.initials: ER
authors.lastname: Nowicki
mesh_terms: D000328:Adult; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000150:complications / Q000401:mortality / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008382:Marfan Syndrome / Q000150:complications / Q000401:mortality / Q000601:surgery*; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011300:Preoperative Care / Q000379:methods; D012092:Replantation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult