Centers that have substantial experience with the David Procedure often are at the forefront of a developing field in cardiac surgery called Aortic Valve Repair (AVr).
It has been shown scientifically that repairing, rather than replacing a different valve called the mitral valve, has been associated with the best long term survival after the procedure, and therefore repair, when feasible, has become the standard of care. In the current era, leaking aortic valves are almost always replaced, rather than repaired, due largely to inconsistent results after repair, and the subsequent need for re-operation.
However, in some centers, led by our European colleagues, aortic valve repair has become more reproducible using a systematic approach to valve repair. Every single David Procedure involves some form of aortic valve repair, or at the very least, every David Procedure has the capacity to result in significant aortic insufficiency if certain principles are not followed. Thus, certain patients with severely leaking aortic valves associated with root aneurysms can be manipulated into becoming completely competent by manipulating certain aspects of the valve and the left ventricular outflow tract. This experience has led some surgeons to apply these techniques to repair leaking aortic valves that are not associated with aneurysms.
The results thus far are extremely encouraging, and even the Mayo Clinic recently reported that aortic valve repair has at least equivalent results (in terms of need for re-intervention) as biological (tissue) valve replacement. Some experts postulate that as valve repair results improve, we will indeed see a similar survival benefit over time, as we do in mitral valve surgery. Valve repair as opposed to replacement offers the following advantages. Mechanical valves ‘last forever’ but require life-long anticoagulation with heavy-duty blood thinners, with at least a 1% per year of both thrombo-embolism (clot) and major bleeding. Tissue valves (cow, pig, and more recently, horse) have limited durability, and historically, many will require re-replacement at 10 years.
Consequently, actuarial survival curves show that after aortic valve replacement, patient long-term survival is significantly lower than that of controls. Further, replacing the valve usually results in immediate correction of the aortic insufficiency (leaking), but also inadvertently causes at least some, but sometimes a significant degree of aortic stenosis (blockage) due to the presence of an obligatory stent associated with the animal tissue. Aortic valve repair results in valve openings that are substantially larger than those of aortic valve replacements, and therefore does not result in this syndrome of ‘functional’ aortic stenosis.
Further, when repair is accomplished, it leaves behind a living structure with the capacity for self-repair in the setting of the minor injuries that usually lead to tissue (animal) valve deterioration over the years. It has already been shown that in patients whose valves have been repaired and re-implanted during a David Procedure that result in minimal aortic insufficiency enjoy the same freedom from valve re-intervention as mechanical valves (‘last forever…’) at 20 years’ follow-up. We have been progressively increasing our experience with AVr, and have had good success thus far repairing both tri-leaflet and bicuspid valves.
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