Isolated Valve-Sparing Aortic Root Replacement (David Procedure) in Aortic Aneurysms and Aortic Regurgitation: Does Marfan Syndrome Influence the Outcome?

All articles of this category (opens in new window) Background: Valve-sparing aortic root replacement (VSRR) is an established treatment for aortic root aneurysms and regurgitation, preserving the native aortic valve and avoiding prosthesis-related complications. Whether Marfan syndrome affects the outcome after VSRR remains controversial. This study analyzed mid-to-long-term outcomes in patients with and without Marfan syndrome undergoing isolated VSRR. Methods: We retrospectively reviewed 157 consecutive patients (44 with Marfan syndrome, 28%) who underwent isolated VSRR between 2006 and 2023. Exclusion criteria were redo operation, aortic dissection, bicuspid aortic valve, aortic arch replacement, and other concomitant procedures. The combined endpoint was death, reoperation/reintervention, relevant aortic insufficiency (≥II), and dissection. Results: Marfan patients were younger (32.1 ± 13.1 vs. 57.4 ± 10.9 years, p < 0.001) and had smaller preoperative ascending aorta (44.0 ± 9.8 vs. 55.6 ± 7.6 mm, p < 0.001) and Sinus of Valsalva diameters (48.1 ± 5.0 vs. 52.2 ± 9.6 mm, p = 0.039). Preoperative relevant aortic insufficiency (≥II) was less frequent in Marfan patients (9.1% vs. 53.2%, p < 0.001). Mean follow-up was 6.3 ± 5.6 years (990 patient-years). Thirty- and 180-day mortality was overall 0.6% ( n = 1). Eleven patients died during follow-up (two Marfan, nine non-Marfan; p = 0.729). Five- and 10-year survival was similar between non-Marfan (96.8%, 94.3%) and Marfan patients (96.7%, 96.7%, log-rank p = 0.521). Aortic or aortic valve reoperation/reintervention was required in 7.6% ( n = 12) overall (6.8% Marfan vs. 8.1% non-Marfan, p = 1.0), of which 3.8% were valve-related and 3.8% aortic. The mean time to reoperation/reintervention was 85.5 ± 55.5 months. Aortic insufficiency ≥ II occurred in 4.5% of Marfan and 6.3% of non-Marfan patients ( p = 1.0). Distal dissection was observed in 4.5% of Marfan and 2.7% of non-Marfan patients ( p = 0.622). The combined endpoint was similar between both groups (15.9% vs. 18.0%, p = 1.0). Univariate Cox regression confirmed that Marfan syndrome was not a significant predictor for the combined endpoint (HR: 0.88, 95% CI: 0.37–2.11, p = 0.78). Conclusion: Isolated VSRR provides excellent early and mid-to-long-term outcomes with low mortality and durable valve function. Although Marfan patients tended to show slightly higher rates of distal aortic dissection, Marfan syndrome was not associated with worse survival or valve dysfunction, though lifelong surveillance remains essential. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany