Current trends in minimally invasive valve-sparing aortic root replacement -- best available evidence

Background: Valve-sparing aortic root replacement such as the re-implantation (David) procedure is becoming increasingly popular. Despite the fact that the procedure is technically more complex, long-term studies demonstrated that excellent clinical outcomes in selected patients with durable repair are achievable. Benefits of minimal access cardiac surgery have stimulated enthusiasm in the use of this approach for valve-sparing aortic root replacement. Methods: We have reviewed available literature on the topic of valve-sparing aortic root replacement (David procedure) via minimally invasive approach through upper hemisternotomy in an attempt to assess current trends and to recognize potential advantages of this technique. Patient selection and preoperative work-up play important role in performing minimally invasive David procedure safely. Surgical technique is similar to the standard David procedure, with several exceptions, and is performed via upper hemisternotomy. Results and Conclusion: Evidence from non-randomized observational and comparative studies demonstrated excellent clinical outcomes of minimally invasive David procedure in selected patients with comparable perioperative mortality to the conventional technique. To date, elective David procedure with a minimal access technique has been performed in low- and intermediate-risk patients. We believe that minimally invasive David procedure could be particularly useful in young patients (Marfan syndrome, bicuspid AV) as it allows faster recovery with improved cosmesis. A decision to perform minimally invasive David procedure should be individualized to each patient and based on the experience of the team. Further large prospective randomized studies with long-term follow-up are still needed to confirm durability of minimal access technique.