How To Perform a David Procedure in a Bicuspid Aortic Valve Using an Upper Hemisternotomy Approach

The David procedure with an upper hemisternotomy approach is feasible and provides an excellent outcome, particularly in young patients. In this case, a preoperative chest CT showed aortic root dilatation measuring 5.8cm. An echocardiogram demonstrated a bicuspid aortic valve (BAV) without significant aortic valve insufficiency (AI). A 6cm upper hemisternotomy incision extending to the right fourth intercostal space was performed. The aorta was transected 1cm above the sinotubular junction.  

Schafers caliper was used to measure the effective height of the nonconjoint cusp. Cusp prolapse must be repaired prior to valve reimplantation and then reassessed after reimplantation. In this case, initial examination of the aortic cusps revealed good coaptation and did not require cusp repair initially. The aortic root was circumferentially mobilized to the level of the aorto-ventricular junction. Then the left and right coronary buttons were created. The noncoronary sinus was excised. Circumferential series of 2-0 Ethibond pledgeted annular sutures were placed in the subvalvular plane in a clockwise fashion.  

The precise height of each commissure was measured, transposed onto the graft, and the graft was trimmed in these areas. The subvalvular annular sutures were passed through the aortic graft. The graft was then positioned and fastened with Cor-Knot over a Hegar dilator. Next, the commissures were secured at the appropriate height within the graft. Subsequently, the circumference of the aortic valve apparatus was secured to the graft with running 4-0 polypropylene sutures.  

The competency of the aortic valve was reassessed. Free-edge plication was performed in the center of the cusp to ensure good coaptation. The left and right coronary anastomoses were performed. The distal anastomosis was completed. The sternum was closed with four wires. A postoperative echocardiogram showed no significant AI, and the patient had an uneventful hospital course.  

A more detailed review of this technique can be found in the authors’ recently published paper in Innovations titled “How We Perform a David Procedure with an Upper Hemisternotomy Approach.” (1). This video was republished with permission from Innovations. 

Reference

1.  Shah, V. N., Kilcoyne, M. F., Buckley, M., Orlov, O. I., Sicouri, S., & Plestis, K. A. (2021). How We Perform a David Procedure With an Upper Hemisternotomy Approach. Innovations, 16(6), 545-552.

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