Key result
Minimally invasive access for the David procedure shows comparable mortality and survival to full sternotomy.
Why the study?
Aortic valve sparing-aortic root replacement (David procedure) has not been routinely performed via minimally invasive access due to its complexity.
Does minimally invasive access yield comparable outcomes to full sternotomy in patients undergoing elective isolated David-I procedures?
Cohort (n=220)
No
Does minimally invasive access yield comparable outcomes to full sternotomy in patients undergoing elective isolated David-I procedures?
Absolute Event Rate: 2.4% vs 0%
p-value: p=0.191
Minimally invasive access for the David procedure appears to offer comparable early and long-term outcomes to conventional full sternotomy, though it requires longer cardiopulmonary bypass and cross-clamp times.
May support minimally invasive David access in select patients; leaves open randomized confirmation of safety and efficacy.
Objectives Aortic valve sparing-aortic root replacement (David procedure) has not been routinely performed via minimally invasive access due to its complexity. We compared our results of elective David procedure via minimally invasive access to those via a full sternotomy. Methods Between 1993 and 2019, a total of 732 patients underwent a valve sparing root replacement (David) procedure. Out of these, 220 patients underwent elective David-I procedure (isolated) without any other concomitant procedures at our center. Patients were assigned to either group A (n = 42, mini-access) or group B (n = 178, full sternotomy). Results Cardiopulmonary bypass time were 188.5 ± 35.4 min in group A and 149.0 (135.5–167.5) in group B (p < 0.001). Aortic cross-clamp time were 126.2 ± 27.2 min in group A and 110.0 (97.0–126.0) in group B (p < 0.001). Post-operative echocardiography showed aortic insufficiency ≤ I° in 41 (100%) patients of group A and 155 (95%) of group B. In-hospital mortality was 2.4% (n = 1) in group A and 0% (n = 0) in group B (p = 0.191). Perioperative stroke occurred in 1 (2.4%) patient of group A and 2 (1.1%) patients of group B (p = 0.483). Reexploration for bleeding was necessary in 4 (9.5%) patients of group A and 7 (3.9%) of group B (p = 0.232). Follow-up was complete for 98% of all patients. The 1-, 2-, 4-, and 6-year survival rates were: 97, 97, 97, and 97%, in group A (mini-access) and 99, 96, 95, and 92% in group B (full sternotomy), respectively. The rates for freedom from valve-related re-operation at 1, 2, 4, and 6 years after initial surgery were: 97, 95, 95, and 84% in group A and 97, 95, 91, and 90% in group B, respectively. Conclusion Early post-operative results after David procedure via minimally invasive access are comparable to conventional full sternotomy. Meticulous attention to hemostasis is a critical factor during minimally access David procedures. Long-term outcome including the durability of the reimplanted aortic valve seems to be comparable, too.
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Shrestha et al. (2022) conducted a cohort in Aortic root pathology requiring valve-sparing root replacement (n=220). Minimally invasive access (upper hemi-sternotomy) vs. Conventional full sternotomy was evaluated on In-hospital mortality (p=0.191). Minimally invasive access for the David procedure resulted in comparable in-hospital mortality (2.4% vs 0%, p=0.191) and long-term survival compared to conventional full sternotomy.
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