title: The David procedure for salvage of a failing autograft after the Ross operation.
abstract: BACKGROUND
  Dilatation of the pulmonary autograft is a major fear after the Ross procedure. We analyzed the results after reoperation for autograft dysfunction using a valve-sparing reimplantation technique (David procedure).
  
  
  METHODS
  From 1995 to 2012, 645 Ross operations were performed, with 630 (98%) of these as freestanding root replacements (mean follow-up, 8.3 ± 4.6 years). Forty-nine autograft reoperations occurred in 46 patients (0.89%/patient-year). Between 2005 and 2013, reoperation using a David procedure was performed in 18 of 35 patients (52%) with autograft dilatation at a mean interval of 11 ± 3.2 years after the Ross operation.
  
  
  RESULTS
  The mean age of 18 patients receiving a David procedure as reoperation was 49.8 ± 13.9 years; 83% were male. The 30-day reoperative mortality was zero. The mean vascular graft size used for reimplantation was 29.5 ± 1.7 mm. At a mean follow-up time of 3.2 ± 2.3 years (100% complete), all patients (18 of 18) were alive and in New York Heart Association functional class I. One patient (5%) needed valve replacement for recurrent aortic regurgitation 2.6 years after the David procedure. In the remaining patients (95%), freedom from aortic regurgitation of grade 2 or greater was 100% at 3 years (regurgitation grade <1, 14 of 17; 82%). Aortic valve gradients were clinically insignificant at 5.8 ± 2.1 mm Hg.
  
  
  CONCLUSIONS
  Performing a David procedure was successful in the vast majority of patients with dilatation of the pulmonary autograft after a Ross operation and revealed good function of the preserved autograft at midterm follow-up. Reoperations could be performed with low perioperative morbidity and mortality.
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Liebrich
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany. Electronic address: timo.weimar@sana.de.
authors.forename: Timo
authors.initials: T
authors.lastname: Weimar
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Tzanavaros
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Detlef
authors.initials: D
authors.lastname: Roser
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Kai-Nicolas
authors.initials: KN
authors.lastname: Doll
authors.affiliation: Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany.
authors.forename: Wolfgang B
authors.initials: WB
authors.lastname: Hemmer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery*; D064592:Autografts; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D011664:Pulmonary Valve / Q000637:transplantation*; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult