Pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique. Results from two European centers

Q: What are the key findings of this study?

Bicuspid aortic valve, higher pre-operative aortic insufficiency, higher NYHA grade, and male sex were independent risk factors for re-operation after the David procedure.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Aortic root aneurysm/disease requiring valve-sparing aortic root replacement (n=1074). Intervention: Bicuspid aortic valve (and other pre/intra-operative risk factors) vs. Tricuspid aortic valve (and absence of other risk factors). Primary outcome: Aortic valve re-operation (OR 2.03, 95% CI 1.18-3.49, p=0.011).

Q: What does this research mean for the field?

Bicuspid aortic valve, higher pre-operative aortic insufficiency, higher NYHA functional class, and male sex are independent risk factors for aortic valve re-operation after the David procedure, whereas older age and larger prosthesis sizes are protective. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Armin Darius Peivandi; Andreas Martens; Felix Fleißner; Ruslan Natanov; Morsi Arar; Florian Helms; Malakh Shrestha; Heike Krüger; Erik Beckmann; Arjang Ruhparwar; Alessandro Leone; Giacomo Murana; Costanza Fiaschini; Davide Pacini; Francesco Campanini

doi:10.3389/fcvm.2026.1881845

August 6, 2026Frontiers in Cardiovascular MedicineOpen Access

Pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique. Results from two European centers

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Key result

Bicuspid aortic valve linked to ~103% greater re-operation risk after the David procedure.

OR 2.03
95% CI 1.18-3.49
P=0.011
n=1,074

Figures

Why the study?

Pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique needed investigation to develop a risk model.

Key Points

To identify pre- and intra-operative risk factors for aortic valve re-operation following valve-sparing aortic root replacement using the David technique and develop a predictive risk model.
Retrospective cohort study across two European centers analyzing patients treated between 07/1993 and 01/2025 (N=1,074) with a median follow-up of 120 (IQR: 141) months.
Primary outcome was aortic valve re-operation, modeled through univariable and multivariable logistic regression analyses.
Model performance was evaluated using receiver operating characteristic analysis for discrimination alongside calibration intercept and slope.
Independent risk factors for re-operation were bicuspid aortic valve (OR: 2.03, 95% CI: 1.18–3.49, p = 0.011), male sex (OR: 1.98, 95% CI: 1.16–3.39, p = 0.012), pre-operative aortic insufficiency grade (OR: 1.61, 95% CI: 1.21–2.14, p = 0.001), and NYHA class (OR: 1.29, 95% CI: 1.0043–1.67, p = 0.046).
Protective factors against re-operation included larger prosthesis size (OR: 0.76, 95% CI: 0.66–0.86, p < 0.001) and older age at operation (OR: 0.98, 95% CI: 0.97–0.996, p = 0.011).
The predictive risk model demonstrated moderate discrimination with an AUC of 0.722 (95% CI: 0.677–0.766) and good calibration (intercept: −0.00, 95% CI: −0.49–0.49; slope: 1.00, 95% CI: 0.75–1.26).

Study Design

Type

Cohort (n=1,074)

Multicenter

Yes

Structured PICO

P

Population

1,074 patients undergoing valve-sparing aortic root replacement using the David technique, followed for a median of 120 months.

E

Exposure

Valve sparing aortic root replacement using the David technique

O

Outcome

Aortic valve re-operationhard clinical

Main Result

Odds Ratio: 2.03 (95% CI 1.18–3.49)

p-value: p=0.011

Limitations

Two-center retrospective cohort design means center-specific influences cannot be ruled out.
Use of a binary re-operation endpoint prevents differentiation between early and late re-operation.
Predictor selection based on univariable p-values can potentially lead to model instability.
The prediction model is based on a single dataset and requires external validation.
Nagelkerke's R2 of 0.140 indicates that other unmeasured risk factors likely impact the outcome.
Lack of detailed geometric data of the valve and echocardiographic data.
Two-center retrospective cohort study (center-specific influences cannot be ruled out)
Binary re-operation endpoint cannot differentiate early vs late reoperation
Predictor selection based on univariable p-values
Prediction model based on a single dataset

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Implication

Bicuspid aortic valve, higher pre-operative AI, NYHA grade, and male sex independently predict re-operation after the David procedure, whereas older age and larger prosthesis size are protective.

Abstract

Background This study investigates pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique to develop a risk model. Methods A retrospective cohort study of two European centers, comprising data from 07/1993 to 01/2025 was performed. Follow up time was 120 (IQR: 141) months. Primary outcome was aortic valve re-operation. Prediction model was developed using uni- and multivariable logistic regression analysis. A risk score was derived. Calibration in the large and slope were performed. Receiver operating characteristic (ROC) analysis allowed discrimination assessment. Results 1,074 patients were included. Male sex (OR: 1.98; 95% CI: 1.16–3.39, p = 0.012), age at operation (OR: 0.98; 95% CI: 0.97–0.996; p = 0.011), pre-operative AI grade (OR: 1.61; 95% CI: 1.21–2.14; p = 0.001), NYHA (OR: 1.29; 95% CI: 1.0043–1.67; p = 0.046), bicuspid aortic valve (OR: 2.03, 95% CI: 1.18–3.49; p = 0.011) and prosthesis size (OR: 0.76; 95% CI: 0.66–0.86; p < 0.001) remained independent predictors in multivariable analysis. The risk model showed moderate discrimination [AUC: 0.722 (95% CI: 0.677–0.766)] and good calibration in the original cohort [intercept: −0.00 (95% CI: −0.49–0.49); slope: 1.00 (95% CI: 0.75–1.26)]. Conclusion Bicuspid aortic valve, higher pre-operative AI, NYHA grade and male sex were independent risk factors for re-operation. Higher age and larger prosthesis sizes were protective factors. Further multi-center research is needed to validate and refine the prediction model.

Discussion

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Cite This Study

Peivandi et al. (2026) conducted a cohort in Aortic root aneurysm/disease requiring valve-sparing aortic root replacement (n=1,074). Bicuspid aortic valve (and other pre/intra-operative risk factors) vs. Tricuspid aortic valve (and absence of other risk factors) was evaluated on Aortic valve re-operation (OR 2.03, 95% CI 1.18-3.49, p=0.011). Bicuspid aortic valve, higher pre-operative aortic insufficiency, higher NYHA grade, and male sex were independent risk factors for re-operation after the David procedure.

synapsesocial.com/papers/6aa6d06f5becb0bc28eee1e1 https://doi.org/10.3389/fcvm.2026.1881845

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Pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique. Results from two European centers

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Pre- and intra-operative risk factors for re-operation after valve sparing aortic root replacement using the David technique. Results from two European centers

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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