Redo Aortic Root Surgery: The David Procedure in a Patient With a Previous Type A Dissection Surgery

Valve-sparing aortic root replacement (VSRR) techniques have transformed the treatment of aortic root and aortic valve disease, providing an important alternative to conventional aortic valve replacement. A paradigm shift toward the preservation of the native aortic valve has gained popularity as the result of its various advantages, including improved patient survival and a reduced incidence of valve-related complications compared to composite valve graft conduits. The benefits of aortic valve preservation and repair are expected to be most significant in younger patients, who are at greater risk of accruing prosthetic valve-related complications over time after valve replacement (1). 

The Tirone David series shows excellent long terms results in terms of reoperation and recurrence of aortic insufficiency (AI) for patients with a tricuspid aortic valve. At the 20-year mark, 69.1 percent of patients were alive and free from aortic valve reoperation, with a cumulative probability of aortic valve reoperation, accounting for death as a competing risk, being just 6.0 percent. The cumulative probability of developing moderate or severe AI was 10.2 percent at 20 years (2). 

The effectiveness of valve-sparing root surgery has been well established in numerous patient series worldwide in experienced surgery centers. Bicuspid aortic valve (BAV) is the most prevalent congenital cardiac abnormality, with an incidence ranging from 0.5 percent to 2 percent (4). Aortic valve insufficiency (AI) often develops at a younger age, usually before the age of 50 (3). 

Several studies have shown that the reimplantation technique, when performed in expert centers, is an excellent treatment strategy for BAV. Arabkhani et al. analyzed the results of BAV aortic valve-sparing procedure in a multicenter study involving 498 patients. They reported a freedom from reintervention rate of 99.1 percent at one year, 95.4 percent at five years, and 89.2 percent at 10 years for patients with isolated AI. For patients with aneurysms 100 percent at one year and 95.4 percent at 10 years, while for patients with AI, these rates were 98.9 percent at one year and 86.4 percent at 10 years. Cusp fenestrations, prolapse, and isolated AI (0.03) were associated with a greater hazard of reintervention (1). 

Lau et al. also reported on a series of 327 valve-sparing surgeries in patients with BAV, concluding that valve-sparing root replacement is reliably performed, regardless of whether cusp reconstruction is necessary. Only a few patients progressed to greater than mild AI, and the need for reoperation is rare in midterm follow-up (4). 

This case presentation shows a challenging scenario involving a 59-year-old woman who had previously undergone aortic replacement of the tubular portion for type A dissection.The sinus portion and aortic valve were preserved; however, during follow-up, the aortic root continued progressive dilatation, eventually reaching the surgical threshold. In this video, the authors show the resolution of this complex case, which involved performing a redo aortic root valve-sparing procedure in a bicuspid aortic valve with a favorable result. 

References

1. Arabkhani B, Boodhwani M, De Paulis R, Chen EP, Koolbergen D, Mastrobuoni S, Aphram G, Salica A, Jahanyar J, El Khoury G, de Kerchove L. Valve-sparing aortic root replacement in bicuspid aortic valves-the reimplantation technique: A multicenter study. J Thorac Cardiovasc Surg. 2025 Feb 17:S0022-5223(25)00120-5. doi: 10.1016/j.jtcvs.2025.02.008. Epub ahead of print. PMID: 39971267.
2. David T. Reimplantation valve-sparing aortic root replacement is the most durable approach to facilitate aortic valve repair. JTCVS Tech. 2021 Jan 28;7:72-78. doi: 10.1016/j.xjtc.2020.12.042. PMID: 34318210; PMCID: PMC8311546.
3. Michelena HI, Desjardins VA, Avierinos JF, et al. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation. 2008;117:2776-2784. https://doi. org/10.1161/CIRCULATIONAHA.107.740878 6.
4. Lau C, Wingo M, Rahouma M, Ivascu N, Iannacone E, Kamel M, Gaudino MFL, Girardi LN. Valve-sparing root replacement in patients with bicuspid aortopathy: An analysis of cusp repair strategy and valve durability. J Thorac Cardiovasc Surg. 2021 Feb;161(2):469-478. doi: 10.1016/j.jtcvs.2019.10.048. Epub 2019 Oct 24. PMID: 31761336.

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