Long-Term Hemodynamic Performance of the Aortic Valve After David I: An Echocardiographic Study

Despite optimal hemodynamics at rest, the performance of the aortic valve under stress conditions long after David I procedure is still debated. From 2001-2014, 73 patients underwent reimplantation with David I technique. Aortic valve function of 13 patients (age 61.2 ± 8.72) with a follow-up of at least 5 years (6.3 ± 0.9 years) was assessed at exercise echocardiographic stress test on a stationary cycle. Patients who had undergone concomitant procedure, with recurrent aortic insufficiency or mitral valve incompetence, were excluded. In all, 8 healthy volunteers served as controls. Transvalvular gradients progressively increased during the steps in both groups (P-within < 0.001), being higher in David patients (P-between < 0.001), but never reaching a clinical significance (David Peak gradient 23.8 ± 9.3 mmHg; Mean gradient 13.2 ± 5.1 mmHg). Effective orifice area (EOA) and EOA index did not change during the test in David patients, whereas Controls showed a progressive increase of functional valve area to a peak at 50 W (Controls EOA 4.0 ± 0.5 cm(2); EOA index 2.0 ± 0.3 cm(2)/m(2)). In conclusion, David I procedure ensures good hemodynamics during high-flow conditions at long-term follow-up. The reimplantation of the functional aortic annulus inside a rigid tube determines a paradoxical reduction of functional aortic valve area, secondary to the increased stroke volume, without any clinically relevant increase in transvalvular gradients. These data confirm the reliability of David I in the long term, even under physical stress conditions.