Valve-sparing aortic root replacement using a straight tube graft (David I procedure)

Objectives: We present our 25-year experience with valve-sparing aortic root replacement using a straight tube graft (David-I). Methods: From 1993 to 2019, 677 patients (median age, 56.0 years; range, 42-65) underwent the David-I procedure with a straight tube graft. A total of 24 different surgeons performed these operations. Marfan syndrome was present in 111 patients (16.4%), and bicuspid aortic valve was present in 71 patients (10.5%). Aortic root aneurysm was present in 544 patients (80.4%), and acute dissection was present in 133 patients (19.6%).Results: Ministernotomy was used in 57 patients (8.4%). Additional cusp plasty was performed in 84 patients (12.4%). Concomitant procedures were coronary artery bypass grafting (n = 122, 18.0%), mitral valve surgery (n = 34, 5%), proximal arch replacement (n = 125, 18.4%), subtotal arch replacement (n = 43, 6.4%), and total arch replacement (n = 102,15.1%). Overall in-hospital mortality was 4.0% (n = 27), and perioperative stroke occurred in 26 patients (3.8%). Postoperative echocardiography showed aortic insufficiency less than I degrees in 600 of 623 (96.3%). The 1-, 5-, 10-, 15-, and 20-year survivals were 97% , 92% , 79% , 68% , and 50% , respectively. The rates for freedom from aortic valve-related reoperation at 1, 5,10, 15, and 20 years were 97% , 92% , 87% , 84% , and 80% , respectively. Multivariate Cox regression analysis identified age (odds ratio, 0.974; 95% confidence interval, 0.957-0.992; P = .004), senior surgeon (odds ratio, 0.546; 95% confidence interval, 0.305-0.979; P = .042), and residual postoperative aortic insufficiency (odds ratio, 4.864; 95% confidence interval, 1.124-21.052; P = .034) as independent risk factors for aortic valve-related reoperation.Conclusions: The aortic valve-sparing David-I procedure can be performed with very low perioperative morbidity and mortality. The short-and long-term results are excellent. The straight tube graft does not lead to increased leaflet erosion. This procedure is reproducible by multiple surgeons. (J Thorac Cardiovasc Surg 2023;166:1387-97)