title: Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease.
abstract: OBJECTIVE
  The durability of valve-sparing aortic root replacement with or without cusp repair in patients with bicuspid aortic valve (BAV) disease is questioned. We analyzed the results of 75 patients with a BAV undergoing Tirone David reimplantation valve-sparing aortic root replacement.
  
  
  METHODS
  Average age was 45 ± 10 years; 80% were male; 31% had 2+ or greater aortic regurgitation (AR); annular diameter averaged 28 ± 3 mm; 32% had a Sievers' type 0 BAV, and 66% underwent concomitant cusp repair (usually cusp free margin shortening) to correct prolapse. Early (6 ± 3 days) and late (2.9 ± 1.7, 1-10 years) postoperative echocardiographic results were compared (cumulative echocardiographic follow-up, 190 patient-years; median late interval, 2 years [interquartile range, 0.68, 4.2]). Seven patients remained at risk beyond 6 years. Clinical outcome and valve function were analyzed using log-rank calculations.
  
  
  RESULTS
  Actuarial survival was 99% ± 2%; freedom from reoperation was 90% ± 5%, infection 98% ± 2%, and stroke 100% at 6 years. After initial improvement in degree of AR (P < .001), minor subclinical progression of AR was observed (P > .5); however, freedom from AR of more than 2+ was 100%. Cusp free margin shortening was not associated with valve deterioration, but commissural suspensory polytetrafluoroethylene neochord creation (n = 4) portended a higher probability of recurrent AR (P = .025).
  
  
  CONCLUSIONS
  After David procedure and cusp repair in patients with a BAV, midterm clinical and valve function outcomes were favorable out to 6 years. More follow-up is required to determine long-term valve durability and the hazard of other clinically important late adverse events, including eventual reoperation, to beyond 10 years.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, Calif 94305-5247, USA.
authors.forename: Fabian A
authors.initials: FA
authors.lastname: Kari
authors.forename: David H
authors.initials: DH
authors.lastname: Liang
authors.forename: John-Peder Escobar
authors.initials: JP
authors.lastname: Kvitting
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Stephens
authors.forename: R Scott
authors.initials: RS
authors.lastname: Mitchell
authors.forename: Michael P
authors.initials: MP
authors.lastname: Fischbein
authors.forename: D Craig
authors.initials: DC
authors.lastname: Miller
mesh_terms: D000328:Adult; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D058385:Cardiac Valve Annuloplasty / Q000009:adverse effects / Q000401:mortality; D003141:Communicable Diseases / Q000209:etiology / Q000601:surgery; D018572:Disease-Free Survival; D005260:Female; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012086:Reoperation; D012092:Replantation / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D055815:Young Adult