Commentary: Learn from the master

John S. Ikonomidis, MD, PhD

Central Message.

A concise but comprehensive description of the reimplantation valve-sparing aortic root replacement is provided by its inventor.

See Article page 72.

I read with great interest the excellent review¹ by Dr David of his extensive experience with the reimplantation valve-sparing root replacement (VSRR), an operation that of course he invented and that is known around the world as the David procedure. This manuscript not only describes the operation in exquisite detail and with clear illustrations but also provides valuable tips and tricks to avoid pitfalls and handle difficult situations, such as aberrant coronary artery anatomy and aortic valve cusp laxity/fenestration. Reading through his step-by-step description of this procedure took me back to my time as a surgery resident at the University of Toronto, where I had the opportunity to observe Dr David perform and teach these procedures firsthand. Later, during my Cardiothoracic Surgery Residency at Stanford University, I was taught to perform this operation, such that when I left for a faculty position at the Medical University of South Carolina in the year 2000, I was the first in the state to offer and perform these procedures. The VSRR, still relatively new, was a “calling card” operation for me that attracted patient referrals from all over the state and beyond. Indeed, when the new Ashley River Tower, originally intended to be a comprehensive Heart and Vascular center, opened at Medical University of South Carolina in 2008, the opening ceremony featured just one clinical vignette, that of a patient in whom I had performed a reimplantation VSRR in 2005. I continue to follow this patient, whose repair remains stable and free from aortic insufficiency, and we have become close friends. The VSRR procedure has played an important part in the development of my career, and for this I am personally indebted to Dr David.

It was interesting to follow the evolution of the reimplantation VSRR operation over the years, with various modifications meticulously undertaken, studied, and reported by Dr David. These reports gave us decisive proof of the superiority of the reimplantation technique over the remodeling operation for annuloaortic ectasia, documented its utility and impressive durability in heritable connective tissue disorders, complicated proximal aortic dissections, and even as a remedial operation for failed Ross procedures. It has also been fascinating to observe the progression in the use of varying Dacron graft configurations for the reimplantation of the aortic root, based upon the belief that each subtle change might result in a more accurate approximation of the native anatomical state, only to find out from analyses of late outcomes that use of a straight Dacron graft as originally described in 1992 was as good as anything. Dr David has always taught that attention to small technical nuances define much of the durability of this operation; this late finding seems to support his assertions.

Experienced reimplantation VSRR operators should study this review and compare their current technical steps with those of Dr David's and, where appropriate, consider some additions or changes. For novices, this review provides a detailed tried and true account, which if carefully read and followed to the letter, will almost ensure procedural success. We should all strive to learn from the masters of our craft when rare opportunities such as this manuscript present themselves.