Twenty-year experience of aortic valve reimplantation using the Valsalva graft: a successful technique with well-made device!

The introduction of the aortic valve (AV) reimplantation, also called David procedure, by David and Feindel in 1992 have placed a milestone for AV sparing [1]. This, one of the most 2 important valve-sparing aortic root replacement operations became the standard technique for patients with aortic root aneurysm with or without AV regurgitation with excellent short- and long-term results [2]. Over the years, the surgical technique of AV reimplantation has evolved significantly from the originally described technique aiming to mimic the anatomical form of the aortic root. Many modifications, including the ‘so-called’ David I–V operations, using different techniques such as plication stitches to create pseudo-/neo-sinuses [3, 4], 2 cylindrical grafts [5] or even special anatomically designed bulged grafts [6] have been described. In this issue of the European Journal of Cardiothoracic Surgery, Chirichilli et al. describe their 20-year-long experience with AV reimplantation using the Gelweave Valsalva graft Vascutek Ltd, Terumo Company (Renfrewshire, Scotland, UK) in 265 patients with aortic root aneurysm with or without AV regurgitation [7]. This device has been designed and invented by the senior author of the current article De Paulis [6] at the end of the last millennium and implemented in the routine practise at the beginning of 2000. The presented study belongs to the largest published cohorts describing AV reimplantation with this graft. The early- and long-term outcomes (mean of 7.1 years) are excellent. The overall survival at 15 years was 87.6 ± 3.4% and freedom from cardiac death was excellent and stable at 99.6 ± 0.4% up to 15 years. Freedom from recurrent AR ≥moderate and freedom from reoperation remained stable up to 15 years at 92.2 ± 2.1% and 95.9 ± 1.6%, respectively. In addition, the incidence of infective endocarditis, thromboembolism and haemorrhage was extremely low. Importantly, a clear message that can be derived from this paper is that David procedure using this particular graft is an excellent and durable option for the surgical treatment of the patients with aortic root aneurysm with or without AV regurgitation. The authors also report that long-term results might have improved after the implementation of routine performance of AV analysis with calliper. First important point that should be discussed is the use of bulged graft in AV reimplantation. There has been a lot of discussion over the years whether the above-mentioned modifications of originally described AV reimplantation technique are potentially leading to better, but also to worse results. David has been using these modifications over the years as well; however, he reported turning back to his original reimplantation technique using a cylindrical graft since 2015. His explanation is that creating neo-sinuses or using manufactured bulged graft adversely affects the durability of AV reimplantation [4]. The only suitable manufactured bulged graft which, in his opinion, would be suitable and not distorting the aortic root and AV geometry, is the anatomically shaped sinus prosthesis (Uni-Graft W SINUS; Braun, Melsungen, Germany). This one is unfortunately no more available. In my opinion, the current study [7] and the study of El Khoury’s group [8] show that excellent results can be achieved even with this technique; however, the results are indeed not as excellent as reported by David et al. [2]. Again here, in my opinion, one of the explanations for this exceptional and almost not reproducible results of David’s cohort is his extreme selection of patients in the increasing course of time. Another important point is the sizing of the graft. From my point of view, the technique described in this article might be not exact enough and somewhat misleading. I would rather propose following the recommendation based on our experience in combination with that of El Khoury et al. [8]. Generally, the largest passable Hegar dilator plus 2 or 1 mm in the case of odd size number, determines the size of the graft. The second part of sizing is to measure the distance from the virtual basal ring plane to the top of the left/non commissure [9]. Finally, based on different studies, including this one, it is of utmost importance to perform dedicated and systematic AV analysis in each AV repair and valve-sparing aortic root replacement, ideally using a caliper, and defining the effective height of each AV cusp, as described by Schafers et al. [10]. In my opinion, this is a clear key to run a successful and durable AV repair and -sparing programme.