How We Perform a David Procedure With an Upper Hemisternotomy Approach

Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve

OBJECTIVE

Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR.

METHODS

There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded.

RESULTS

In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05).

CONCLUSIONS

The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.

Valve-sparing David procedure via minimally invasive access does not compromise outcome

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.