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Anatomy determines the close vicinity of the sinuses of Valsalva and the aortic valve leaflets. Therefore, the aortic valve has to be involved in any planning of surgery on the critically dilated aortic root. This is particularly true in patients with little or no structural changes of the valvular leaflets, because these valves can be considered potentially retainable regardless if they are tricuspid, bicuspid, competent, or regurgitant. The surgical challenge therefore resides in the need for a procedure that enables resection and replacement of diseased sinuses while preserving and/or restoring both function and anatomy of the aortic valve.
In 1993, we adopted a method for aortic valve reimplantation, which was described by T. David 1 year earlier. Meanwhile, we have used this technique in more than 300 patients with retainable aortic valves for 3 reasons:
It appears to provide long-term stability of the aortic annulus.
The procedure is relatively hemostatic.
The procedure is teachable to many surgeons with some interest in surgery on the aortic root.
With ongoing experience, we have expanded its use from patients with aneurysms of the aortic root to patients with aortic dissection too. The latter indication is still a matter of reasonable debate given the fact that aortic valve reimplantation takes somewhat more time compared with the implantation of a valved conduit or supracoronary replacement of the ascending aorta. On the other hand, this operation is probably the best treatment of the dissected aortic root, because most of the diseased vessel wall may be resected and replaced by a vascular graft while at the same time retaining the valve.
Likewise, many surgeons regard aortic valve reimplantation as the first choice for aortic root aneurysm in patients with Marfan syndrome who do not present with pronounced leaflet prolapse or extensive fenestrations in the valvular commissures. Whether this opinion will withstand the test of time is currently challenged by a prospective, multicenter clinical trial initiated by members of the National Marfan Foundation.
Using the original so called T. David type I procedure, we have remained resistant to the evolution, which this procedure has undergone in the meantime. However, our follow-up data well justify this attitude, because the incidence of reoperation for late valve failure has remained acceptable.
Operative Technique of the David Type I Procedure
The technique of aortic valve reimplantation can be used in many cases of aortic root aneurysm whenever the aortic valve is not stenotic and/or calcified. Central mild-to-moderate regurgitation can be corrected very often, whereas eccentric regurgitation may be more difficult to treat by this technique alone.
Aortic valve reimplantation is a safe and straightforward procedure with a well predictable outcome once a few key issues are addressed. The decision on whether to retain the valve should be founded on careful examination of the valvular leaflets for structural changes, such as dense calcifications, large fenestrations, or severe valve prolapse. Once the decision to retain the valve has been made, the aortic root has to be mobilized around its entire circumference except for a small segment of the perimeter near the membranous septum. Excision of the sinuses should be done with utmost care so as not to damage the valvular leaflets. The buttons of the excised coronary ostia must be mobilized enough to allow for tension-free reimplantation into the graft. Sizing of the graft is a key issue too. The commissures need to be trimmed high enough into the vascular graft to prevent later prolapse. The suture lines for reimplantation of the neocoronary sinuses and the coronary ostia must be blood tight in the first place, because secondary hemostatic sutures may be difficult to position.
Even though evolution of this procedure toward a more physiological operative result is attractive for theoretical reasons, we still trust the original David type I operation and we believe that our confidence is well supported by the favorable follow-up data we have obtained so far.