Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It?
BACKGROUND
Valve-sparing aortic root replacement has already proven its excellent long-term results, with low valve-related complications comparable with conventional aortic valve replacement. The aim of this study was to investigate whether additional expanded cusp repair is an alternative with comparable results.


METHODS
Data of 192 elective patients undergoing valve-sparing aortic root replacement were prospectively recorded: 58 patients (30.2%) received an isolated aortic root replacement (group I, isolated David), and 134 patients (69.8%) received additional cusp repair (group II, complex David), such as plication of the free margin (n = 77), decalcification (n = 45), or pericardial patch (n = 39). Cumulative follow-up was 480 patient-years, with a mean of 2.5 ± 1.5 years.


RESULTS
Mean age was 60 years, and 76.6% were men. In hospital mortality was 3.4% in group I and 0.0% in group II. Freedom from cardiac death at 5 years (by Kaplan-Meier estimation) was 83% vs 98% (p = 0.058). Freedom from moderate or severe aortic insufficiency at 5 years was 100% in group I vs 93% (95% confidence interval, 86% to 97%) in group II (p = 0.110). Seven patients required reoperation for aortic insufficiency or stenosis: repeat repair (n = 3), Ross procedure (n = 2), and biologicical aortic valve replacement (n = 2). Freedom from reoperation at 5 years was 96% (95% confidence interval, 76% to 99%) in group I vs 89% (95% confidence interval, 71% to 96%) in group II (p = 0.305).


CONCLUSIONS
Overall survival and freedom from reoperation after valve-sparing aortic root replacement, even with additional complex cusp repair, provides excellent midterm results. Low risk of valve-related complications and absence of anticoagulation therapy are distinctive advantages of this complex procedure.
Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany. Electronic address: hardy.baumbach@rbk.de.
Hardy
H
Baumbach
Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
Kristina
K
Wachter
Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
Ragi
R
Nagib
Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
Samir
S
Ahad
Department of Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom.
Rashmi
R
Yadav
Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
Adrian
A
Ursulescu
Department of Anaesthesiology, Robert-Bosch-Hospital, Stuttgart, Germany.
Matthias
M
Hansen
Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
Ulrich
U
Franke
D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome