The David's valve-sparing aortic root replacement method is a surgical treatment for aortic root aneurysms. With this method, the aneurysm is repaired while the patient's own aortic valve is preserved. This method helps to avoid the use of long-term anticoagulant (blood-thinner) medication and may reduce the risk of stroke or endocarditis.
If the patient's own aortic valve is diseased or cannot be used during the aorta surgery, a bioprosthetic valve can be used to avoid the use of long-term anticoagulation.
While the David's valve-sparing aortic root replacement method has many benefits, it is also a technically difficult aorta surgery procedure. Dr. Lars G. Svensson, Director of the Center for Aortic Surgery, Marfan Syndrome and Connective Tissue Disorders Clinic at Cleveland Clinic, has developed a modified version of the David's procedure. The Modified David's Reimplantation Procedure helps to determine the appropriately sized aorta graft, maintain the left ventricular outflow tract (the passageway out of the left ventricle), and improve outcomes when using the valve-sparing method.
Two options for incisions for this method of surgery to treat Marfan syndrome
- Traditional - 8 - 12 inch incision for the David reimplantation
- Minimally invasive skin incisions for other valve replacements
The goal is to limit incision size.
The aorta is cut, just above the aortic valve annulus and the coronary ostia (openings where the coronary arteries are attached to the aortic root). The diseased portion of aorta is removed.
Sutures are placed just below the aortic valve, around the left ventricular outflow tract.
A collagen-coated, polyester graft is used for the portion of the aorta being replaced.
Sutures are placed through the graft.
A special piece of equipment, called a Hegar's dilator, is placed in the left ventricular outflow tract, through the aortic valve. The size of the dilator is based on the patient's body size and the expected size of a normal left ventricle outflow tract.
The sutures are then tied around the dilator, to shape the bottom portion of the aorta graft, similar to a natural aortic root.
Next, the aortic valve is re-implanted into position within the aorta graft. The valve is tested to make sure it opens and closes properly.
Then, small holes are produced in the aorta graft for the coronary ostia (openings). The coronary arteries are re-attached through the small holes.
The graft is then sewn to the aorta. If the aortic arch needs to be replaced, a separate graft is sewn from the aortic arch to the aortic root graft (as illustrated).
The Modified David approach is a successful approach to aortic valve sparing surgery. With this procedure, the outflow tract size is maintained, a more normal aortic root is established, and valve function is improved.
Before Marfan syndrome surgery - notice the arrow - the enlarged dissected aorta in a patient with acute aortic dissection, a life threatening complication of Marfan Syndrome.
Photographs from an operation where the aortic valve and coronary arteries are to be re-implanted into a new tube replacement of the aortic root.
Photograph of dacron aortic graft
Sutures are sewn through the annulus of the aortic valve and the bottom portion of the dacron graft
The graft is being lowered into place, around the outside of the aortic valve.
If you peer inside the graft (top view), you can see the aortic valve. The aortic valve is secured within the new tube and the coronary arteries are reattached. The end of the graft is then sewn to the aorta.
The final result. With this operation, patients do not need to be on blood thinners for the rest of their lives. This operation has good long-term results in patients with Marfan Syndrome if done early in the disease process.
The patient's view - after healing
What is the aortic root?
The aortic root is the section of the aorta (the large artery leaving the heart) that is attached to the heart. The aortic root includes the annulus (tough, fibrous ring) and leaflets of the aortic valve; and the openings where the coronary arteries attach (coronary ostia).
Illustration of aortic root aneurysm before aorta surgery
What is an aortic root aneurysm?
An aneurysm is an abnormal bulge in the wall of a blood vessel. In some patients, an aneurysm can occur at the aortic root, causing the aorta to dilate or widen and the aortic valve to leak.
Without treatment, a life-threatening condition called aneurysm dissection can occur. In this condition, blood flows through a tear in the inner layer of the aorta, causing the layers to separate. Blood flow becomes interrupted and causes the arterial wall to burst.
From Cleveland Clinic:
- Svensson LG, Blackstone EH, Alsalihi M, Batizy LH, Roselli EE, McCullough R, Vivacqua A, Moran RT, Gillinov AM, Thamilarasan M, Griffin B, Hammer DF, Stewart WJ, Sabik JF 3rd, Lytle BW. Midterm results of David reimplantation in patients with connective tissue disorder. Ann Thorac Surg. 2013 Feb;95(2):555-62. doi: 10.1016/j.athoracsur.2012.08.043. Epub 2012 Dec 31
- Svensson LG, Al Kindi AH, Vivacqua A, Pettersson GB, Gillinov AM, Mihaljevic T, Roselli EE, Sabik JF 3rd, Griffin B, Hammer DF, Rodriguez L, Williams SJ, Blackstone EH, Lytle BW. Long-term durability of bicuspid aortic valve repair. Ann Thorac Surg. 2014 May;97(5):1539-47; discussion 1548. doi: 10.1016/j.athoracsur.2013.11.036. Epub 2014 Mar 27
- Svensson LG, Batizy LH, Blackstone EH, Gillinov AM, Moon MC, D'Agostino RS, Nadolny EM, Stewart WJ, Griffin BP, Hammer DF, Grimm R, Lytle BW. Results of matching valve and root repair to aortic valve and root pathology. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1491-8.e7. doi: 10.1016/j.jtcvs.2011.04.025. Epub 2011 Jun 17
- Svensson LG, Cooper M, Batizy LH, et al. Simplified david reimplantation with reduction of anular size and creation of artificial sinuses. Ann Thorac Surg 2010;89:1443-7.
- Svensson LG. Sizing for Modified David's Reimplantation Procedure. Ann. Thoracic Surg. 2003;76:1751-1753.*
- David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J. Thorac. Cardiovasc. Surg. 1992; 103:617-621.*
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