David aortic valve-sparing reimplantation versus biological aortic root replacement: a retrospective analysis of 411 patients

Objectives This study aimed to compare short- and long-term results for patients undergoing either aortic valve-sparing reimplantation (David) procedure (AVr-D) or biological aortic root replacement (Bentall) procedure (ARr-B-bio) for aortic root pathology. Methods We compared outcomes for patients who underwent AVr-D ( n = 261) or ARr-B-bio ( n = 150) between 2000 and 2015 at our institution. The mean age of patients was 55 ± 13 years and 21.7% ( n = 89) were female. ARr-B-bio patients were significantly older than AVr-D patients (58 ± 10 vs 53 ± 15 years, p < 0.001) and had a significantly lower incidence of connective tissue disorders (2.0% vs 16.9%, p < 0.001). Follow-up was complete in 88% of patients. Results Mortality at 30 days was 1.2% ( n = 5) overall, at 0.4% ( n = 1) significantly lower in the AVr-D group compared with 2.7% ( n = 4) in the ARr-B-bio group ( p = 0.04). Postoperative low cardiac output was more common in ARr-B-bio patients ( n = 4) versus AVr-D patients ( n = 0; p = 0.008). The occurrence of postoperative strokes was 2.2% ( n = 9) in both groups, without significant differences ( p = 0.84). Five- and ten-year survival was 93.7 ± 1.8% and 84.4 ± 4.7% in patients who received AVr-D and 90.9 ± 2.6% and 84.6 ± 5.4% for ARr-B-bio patients (log-rank p = 0.37). Using Cox regression analysis, age (HR 1.06; 95% CI 1.02–1.10, p = 0.002), smoking (HR 2.74; 95% CI 1.28–5.86, p = 0.01), and emergency surgery (HR 6.58; 95% CI 1.69–25.54, p = 0.007) were found to be independent predictors of long-term mortality. There was no difference in freedom from reoperation between AVr-D (89.4 ± 3.4% at 10 years) and ARr-B-bio (80.4 ± 7.5% at 10 years, log-rank p = 0.66) patients, nor for freedom from stroke, bleeding, myocardial infarction, or endocarditis during follow-up. Conclusions Short-term outcomes for both AVr-D and ARr-B-bio are excellent in patients with aortic root pathology. The long-term outcomes were associated with comparable survival and freedom from reoperation. AVr-D may be preferable to ARr-B-bio in patients with suitable pathoanatomy.