Long-term results of the David Procedure in patients with acute type A aortic dissection

The David Procedure may provide an attractive alternative to aortic root replacement in patients with aortic valve insufficiency (AI) even in the emergency setting of an acute type A aortic dissection (AAD).

From 1996 to 2011 the David Procedure was performed in 23 patients with AAD in our department. Patients' mean age was 49 ± 15 years and 70% (n = 16) were male. Concomitant hemiarch replacement was performed in 19 patients while the remaining 4 patients underwent full arch replacement. Additional leaflet prolapse was corrected by plication in 5 cases. A modification of the classic David technique was performed by creating a pseudosinus in 6 patients (26%) and a neosinus in 9 patients (39%). Mean follow up was 7.7 ± 3 years.

Thirty-day mortality was zero. There were 4 late deaths (17%). One patient suffered a perioperative neurologic event (4%). One further patient suffered a late stroke during follow up (0.6%/pt-yr). Three patients (1.7%/pt-yr) required aortic valve reoperation during follow up: in 2 cases leaflet perforation was observed, and one patient had to undergo valve replacement because of endocarditis with severe AI. There were two cases of bleeding events (1.1%/pt-yr) at follow up. The linearized rate for recurrent AI ≥ 2° was 1.1%/pt-yr.

The David Procedure certainly provides a challenging option to treat selected young patients with AI in the presence of AAD. However, current data suggest that it is safe and feasible.

Long-term valve-related events of the David Procedure applied in emergency cases are rare and aortic valve function remains stable for many years.