Valve-Sparing or Valve-Preserving Surgery (Reimplantation Surgery)

Overview

What is a valve-sparing aortic root replacement?

A valve-sparing aortic root replacement is a type of heart surgery on the main artery coming out of your heart that transports oxygen-rich blood to your body (aorta).

The area of your aorta that attaches to your heart (aortic root) has a one-way valve made of flaps of tissue that open and close to release oxygen-rich blood from your heart (aortic valve). Your healthcare provider performs this surgery when your valve is healthy but there’s something wrong with your aorta (such as it being too big, an aneurysm). Valve-sparing aortic root replacement replaces your aortic root while keeping your own aortic valve.

Traditional aortic root replacement surgery involves replacing your aortic valve with an artificial valve. Keeping your own aortic valve can lessen the need for procedures over the long term while avoiding the need for blood thinners.

Valve-sparing aortic root replacement is also called the David procedure. Canadian surgeon Dr. Tirone David first performed the procedure in 1989.

Who needs to have a valve-sparing aortic root replacement?

Surgeons may perform the David procedure if you have conditions that affect your aortic root, such as:

What conditions are treated with a valve-sparing aortic root replacement?

The David procedure treats an abnormal bulging or enlargement of your aortic root wall (aortic root aneurysm). Aortic root aneurysm may or may not include a leaky heart valve (aortic insufficiency or aortic regurgitation).

Surgeons also use valve-sparing aortic root replacement to prevent:

  • Bursting of the aortic root aneurysm.
  • Tearing of the inner layer of your aorta (aortic dissection).

Why is a valve-sparing aortic root replacement done?

Surgeons may use valve-sparing aortic root replacement as an alternative to aortic valve surgery. Aortic valve surgery replaces your own aortic valve with a:

  • Valve from a donated human heart (homograft).
  • Valve made of mechanical parts (mechanical valve).
  • Valve made of tissue (biological valve).

Your healthcare provider may suggest valve-sparing aortic root replacement when you have a healthy aortic valve. This means your aortic valve:

  • Has no calcium build-up (calcification).
  • Isn’t damaged.
  • Works properly or is reparable.

What are the types of valve-sparing aortic root replacement?

The David procedure is a type of traditional open surgery, generally using one large (8-inch to 12-inch) incision.

Procedure Details

What happens before a valve-sparing aortic root replacement?

Before a valve-sparing aortic root replacement, your surgeon will explain the procedure and inform you about the risks. Tell your healthcare provider about your:

Before the David procedure, your healthcare provider may perform tests, including:

They’ll give you specific instructions to prepare for your surgery. For instance, they may ask you not to drink or eat anything after midnight the night before your procedure.

What happens during a valve-sparing aortic root replacement?

On the day of the valve-sparing aortic root replacement, you should wear comfortable clothing. You’ll need to wear a hospital gown during the procedure.

Right before the procedure, you may get:

  • An IV line in your arm for fluids and medications.
  • A sedative to relax you.
  • Medication through the IV to make you sleep (general anesthesia).

During the David’s procedure:

  1. Your surgeon makes one large cut in your chest.
  2. They attach a heart-lung machine (cardiopulmonary bypass) to your heart to pump blood through your body and help you breathe.
  3. They inject a cold solution into your heart to stop it.
  4. Your surgeon places a clamp across your aorta.
  5. They cut away the enlarged ascending aorta and parts of your aortic root, and separate your coronary arteries from your aortic root.
  6. After they separate your healthy aortic valve from the enlarged aorta, a synthetic tube (graft) is placed over the valve and secured to your heart.
  7. The valve is then reimplanted inside the synthetic tube graft. The graft replaces the enlarged aortic root.
  8. They reattach your coronary arteries to the graft.
  9. Your surgeon will make sure blood runs properly through the valve. Then, they stop the heart-lung machine.
  10. They close the incisions with surgical staples or stitches.

What happens after a valve-sparing aortic root replacement?

After a valve-sparing aortic root replacement, you’ll need to stay in the hospital for up to a week. Your healthcare provider will give you follow-up instructions, such as:

  • Drink only liquids for at least a day after surgery.
  • Start to walk one or two days after surgery.

They’ll remove any surgical staples or stitches one to three weeks after the surgery.

Risks / Benefits

What are the advantages of valve-sparing aortic root replacements?

The advantages of valve-sparing aortic root replacements include:

  • Excellent long-term survival rates.
  • Low rates of complications such as thromboembolism or bleeding events.
  • No need for future replacement surgery of artificial valves.
  • No need to take long-term blood thinners (anticoagulants).

What are the risks or complications of valve-sparing aortic root replacements?

The risks of valve-sparing aortic root replacements include:

  • Aortic insufficiency.
  • Aortic valve leaflets that stretch or weaken (aortic valve cusp prolapse).
  • Aortic stenosis.

Recovery and Outlook

What is the recovery time after a valve-sparing aortic root replacement?

Complete full recovery time after a valve-sparing aortic root replacement can be from four to six months, but people return to work at around two months. Try not to lift anything that may cause strain for at least six weeks and avoid strenuous exercise for at least three months. Walking a little each day and getting enough sleep can help you recover.

Your healthcare provider may also recommend cardiac rehab. During cardiac rehab, you’ll learn tips for:

When can I go back to work or school, drive or eat?

If you have the David procedure, you can go back to work or school and start driving in about six weeks.

You can usually return to your regular diet several days after the procedure if you feel up to it. It may take up to a month to feel as hungry as usual.

What is life expectancy after a valve-sparing aortic root replacement?

After a valve-sparing aortic root replacement, most people can expect to live a full lifespan.

When to Call the Doctor

When should I see my healthcare provider?

Talk to your healthcare provider if you have any of these symptoms after your surgery:

Seek emergency care immediately if you have:

A note from Cleveland Clinic

Valve-sparing aortic root replacement (David procedure) replaces a damaged aortic root while keeping your own aortic valve. Surgeons use this heart surgery to treat a bulging or enlarged aortic root wall (aortic root aneurysm). Valve-sparing aortic root replacement can also help prevent the bursting of aneurysms and tearing of the inner wall of your aorta. You can usually return to work and drive about six weeks after surgery, though full recovery time may take four to six months.

Last reviewed by a Cleveland Clinic medical professional on 05/17/2022.

References

  • Buratto E, Konstantinov IE. Valve-sparing aortic root surgery in children and adults with congenital heart disease. (https://www.jtcvs.org/article/S0022-5223(20%2932674-X/fulltext) J Thorac Cardiovasc Surg. 2021 Sept 1;162(3):955-962. Accessed 5/17/2022.
  • David, TE. Aortic Valve-Sparing in Different Aortic Valve and Aortic Root Conditions. (https://www.sciencedirect.com/science/article/pii/S0735109716333605?via%3Dihub) J Am Coll Cardiol. 2016 Aug 9;68(6):654-664. Accessed 5/17/2022.
  • David, TE. Aortic Valve-Sparing Operations: A Review. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3413824/) Korean J Thorac Cardiovasc Surg. 2012 Aug;45(4):205-212. Accessed 5/17/2022.
  • Harky A, Antoniou A, Howard C, Rimmer L, Ahmad MU, Bashir M. Valve-sparing aortic root surgery: from revolution to evolution? (https://jovs.amegroups.com/article/view/23889/html) J Vis Surg. 2019 Feb 13;5:14. Accessed 5/17/2022.
  • Shrestha M, Krueger H, Umminger J, et al. Minimally invasive valve-sparing aortic root replacement (David procedure) is safe. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384253/) Ann Cardiothorac Surg. 2015 Mar;4(2):148-153. Accessed 5/17/2022.

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