Valve-sparing root replacement (VSRR) has been performed for more than 30 years, both electively and in emergencies, with excellent long-term clinical outcomes. There are 2 main types of VSRR: the reimplantation (David) and the remodeling (Yacoub) procedures. Indications for the procedure, root dimension thresholds, and age at intervention can vary widely as VSRR addresses a range of conditions, from genetic aortopathies to sporadic root dilatation or acute type A dissections. Regardless of the underlying cause, preserving the native aortic valve is associated with improved survival compared with composite valve grafting (CVG).

 In addition, VSRR avoids key limitations associated with mechanical and bioprosthetic CVG, including risks of thromboembolism, bleeding, prosthetic valve infection, and structural degeneration, particularly in younger patients.

 

However, VSRR is not a one-size-fits-all procedure. Not every patient is a good candidate for valve preservation, and successful outcomes rely on the expertise of the surgeon to make crucial decisions at various stages. With that in mind, we have distilled the key clinical and technical considerations for valve-sparing aortic root replacement in adults into the following 10 commandments.

 

This article will focus specifically on the reimplantation (David) procedure, which was pioneered at our institution.