Aortic Valve-Sparing Root Replacement in Patients with Bicuspid Aortic Valve Disease: A Single-Center 12-Year Experience

All articles of this category (opens in new window) Background: Aortic valve-sparing root replacement (David procedure) in patients with bicuspid aortic valve (BAV) disease is an established but technically demanding alternative to conventional aortic valve replacement techniques. Successful repair depends not only on stabilizing the aortic root but also on addressing intrinsic cusp pathology. Adjunctive repair techniques have been described, yet two central challenges persist: achieving perfect leaflet coaptation and a durable restoration of valve competence with long-term freedom from reoperation. Despite encouraging early experiences, data on mid-term and long-term outcomes of the David procedure in BAV patients still remain limited. Methods: Between January 2013 and September 2025, 27 consecutive patients with BAV underwent valve-sparing root replacement (David procedure) with or without leaflet repair at our institution. Leaflet repair techniques included cusp plication, cusp decalcification, closure of cusp fenestrations, commissural cleft closure, and free margin reinforcement with running suture. A 12-year clinical follow-up was conducted by clinical interview and echocardiographic examination. Mean clinical follow-up duration was 3.0 ± 3.2 years (range [0.1−12 years]). Follow-up was successfully completed in 85% of the patients. The primary endpoints were freedom from reoperation, freedom from aortic regurgitation (AR) > II, and cardiac mortality. Results: Mean patient age was 42.7 ± 10.9 years, and the majority of patients were male (92.6%). Preoperative left ventricular ejection fraction (LVEF) averaged 60.3 ± 5.1%, with a mean LVEDD of 59.3 ± 8.59 mm. Nineteen (70.4%) patients required additional leaflet repair. Mean cardiopulmonary bypass and cross-clamp times were 199 ± 40 and 137 ± 20 minutes, respectively. Postoperative freedom from AR > II was 100%. 30-day mortality and postoperative stroke rate were 0%. Two patients (7.4%) required reoperation by early recurrent AR > II within 6 months. Cardiac mortality remained 0% during follow-up. Mean LVEDD during follow-up was 52.7 ± 4.4 mm. Conclusion: Our single-center experience demonstrates that aortic valve-sparing root replacement in BAV patients is a safe and reproducible procedure, which provides excellent early to long-term outcomes. However, adjunctive leaflet repair techniques seem to be needed in the majority of patients to ensure durable valve repair. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany