{"id":4708,"date":"2024-07-17T22:39:14","date_gmt":"2024-07-17T22:39:14","guid":{"rendered":"https:\/\/www.heart-valve-surgery.com\/learning\/?page_id=4708"},"modified":"2024-07-26T10:37:54","modified_gmt":"2024-07-26T10:37:54","slug":"modified-david-reimplantation-procedure","status":"publish","type":"page","link":"https:\/\/www.heart-valve-surgery.com\/learning\/modified-david-reimplantation-procedure\/","title":{"rendered":"Modified David Reimplantation Procedure: What Should Patients Know?"},"content":{"rendered":"<p>We were privileged to have <a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Lars-Svensson-Cleveland-Ohio.php\">Dr. Lars Svensson<\/a>, Chief, Heart, Vascular &amp; Thoracic Institute at Cleveland Clinic, collaborate with us in the following &#8220;Surgeon Q&amp;A Interview&#8221; about the Modified David Reimplantation Procedure. His surgical experience and extensive research have led to many innovative surgical treatments and techniques, including the Modified David Reimplantation Procedure to replace the aortic root while sparing the aortic valve.<\/p>\n<p>In this video, Dr. Svensson explains the advantages of keeping the native aortic valve rather than replacing it with a mechanical or biological valve and the overall patient outcomes for reimplantation procedures. If you are a patient with an enlarged aortic root and weighing your options for surgery, this comprehensive questions-and-answers session should give you the answers you need for an informed conversation with your surgeon about how to proceed for a successful surgical outcome.<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"YouTube video player\" src=\"https:\/\/www.youtube.com\/embed\/hOm3b0rPPgI?rel=0\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h2>An Introduction to Dr. Svensson<\/h2>\n<p>\u201cI\u2019m Lars Svensson. I\u2019m Chairman of the Heart and Thoracic Institute at the Cleveland Clinic, and I\u2019m also the lead surgeon and the Director of the Marfan\u2019s and Connective Tissue Disorders Clinic. Today, we will be talking about the operations done on the aortic root, particularly what we often refer to as the Modified David Reimplantation Operation.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Lars-Svensson-Cleveland-Ohio.php\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full\" src=\"https:\/\/www.heart-valve-surgery.com\/profileImages\/154_129_172.jpg\" alt=\"Dr. Lars Svensson\" width=\"129\" height=\"172\" \/><\/a><br \/>\n<a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Lars-Svensson-Cleveland-Ohio.php\">Dr. Lars Svensson<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>\u201cIt\u2019s important to understand that there are different names for these procedures,\u201d Dr. Svensson said. \u201cThere\u2019s valve preserving, where the valve is kept, which can be either done by the remodeling or reimplantation operation.<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4758 size-full aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/aortic-root-hvs-img.png\" alt=\"Aortic Root Heart Model\" width=\"650\" height=\"365\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>There\u2019s also what\u2019s called valve-sparing, which is also preservation of the aortic valve leaflets. And again, there\u2019s the reimplantation or the remodeling operation. What we\u2019re going to be talking about is the modification I introduced some 25 years ago, maybe a bit more, for the David Reimplantation Operation.<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4759 size-full aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/aortic-root-procedure-names.png\" alt=\"Aortic Root Procedure Names\" width=\"650\" height=\"363\" \/><\/p>\n<p>&nbsp;<\/p>\n<h2>What is the modification for the David Reimplantation Operation?<\/h2>\n<p>\u201cThe modification involves putting pledgets on the valve sutures that are used to implant the valve and the freed up aortic valve, what we call the left ventricular outflow tract, into a new plastic tube,\u201d said Dr. Svensson.\u00a0 In addition, the way I started doing it was using what\u2019s called a Hegar\u2019s dilator and tying the sutures down around a Hegar\u2019s dilator that is the correct size for somebody\u2019s body surface area, in other words, size. The importance of that is, firstly, as far as pledgets, I noticed that in some of Tyrone David&#8217;s early series, there were sutures that pulled through the mitral valve or other parts of the left ventricular outflow tract and caused fistulas. In other words, openings into different chambers of the heart or damaged surrounding areas. The pledgets make it more secure.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4760 size-full aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/pledgets-sutures.png\" alt=\"Modified David Procedure Pledgets on Sutures\" width=\"650\" height=\"363\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>Dr. Svensson continued, \u201cSecondly, it&#8217;s not only the aortic root that increases in size; the annulus, which is where the leaflets are attached, also increases. So the reason for the Hegar\u2019s dilator is to bring it down to a normal size, and I\u2019m convinced that is one of the reasons we have such good long-term results with the reimplantation operation that we modified.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>What are the benefits of keeping the native aortic valve?<\/h2>\n<p>\u201cThere are a number of benefits to keeping the native valve,\u201d Dr. Svensson said. \u201cOur long-term data shows that the valves hold up very well. The risk of infection is much lower, and the risk of stroke is much lower. In addition, if a young person needs an operation for the aortic root or the aortic valve, they usually get offered a complex operation such as the Ross procedure or a mechanical valve.\u201d<\/p>\n<p>\u201cWith a mechanical valve, you have to stay on Coumadin for the rest of your life. A biological valve, if that&#8217;s what you choose, is going to fail depending on somebody\u2019s age, anywhere between 5 and 10 years, and then one gets into a sequence of multiple procedures. So, with a reimplantation operation, we know the long-term results are much better.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>What are the patient outcomes?<\/h2>\n<p>\u201cOne of my trainees, one of the residents, has just analyzed my own data, some 530 patients that I&#8217;ve done over the last 20 years, and there were no deaths in that series, and in detail, she analyzed 491 patients that we had long-term follow-up. Ninety-six percent of those patients still had a good functioning valve that had not required a re-operation 15 years after surgery. In other words, if 100 patients had the operation, only four of those patients needed another operation within 15 years of having the modified reimplantation operation.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4761 size-full aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/modified-david-procedure-patient-outcomes.png\" alt=\"Modified David Procedure Pledgets on Sutures\" width=\"650\" height=\"364\" \/><\/p>\n<p>&nbsp;<\/p>\n<h2>What are the outcomes for patients with connective tissue disorders?<\/h2>\n<p>Dr. Svensson told us they did an analysis of 214 patients with connective tissue disorders who underwent a reimplantation and modification procedure. He said, \u201cThere were no operative deaths, and the freedom from reoperation at 12 years was 95 percent. So, the reoperation holds up very well long-term.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Can the Modified David Reimplantation Procedure be used for patients with bicuspid aortic valves, aortic stenosis, and\/or aortic regurgitation?<\/h2>\n<p>\u201cIn patients with bicuspid valves, which is about one to two percent of the population, the ideal operation for somebody who has an enlarged aortic root and a bicuspid valve that\u2019s leaking is really not clearly defined,\u201d said Dr. Svensson. \u201cFor patients who have stenosis, calcium buildup on their bicuspid valve, and enlarged root, we go ahead and do a composite valve root replacement, a so-called <a href=\"https:\/\/consultqd.clevelandclinic.org\/reimplantation-vs-bentall-root-procedure-for-aortic-root-aneurysm-which-to-choose\">Bentall operation<\/a>.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4762 size-full aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/bentall-procedure.png\" alt=\"Bentall Procedure\" width=\"650\" height=\"361\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>\u201cIn patients with a leaking valve and enlarged root, our data would suggest that the reimplantation operation is probably the best way to go. Our data also suggests that the difference is not significant at this stage between the three leaflet valves and two leaflet valves, the bicuspid valves. They\u2019re holding up pretty well, but we know from other research that bicuspid valves are abnormal and will break down over time.\u201d<\/p>\n<p>\u201cWe also do a lot of remodeling operations for bicuspid valves, but I think, on the whole, the reimplantation operation is probably the better way to go for patients with bicuspid valves.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Is it common for patients with aortic valve disease and an enlarged root to have symptoms?<\/h2>\n<p>\u201cThere are patients who have symptoms before the operation and those who don\u2019t,\u201d said Dr. Svensson. \u201cThe symptoms are related to the aortic valve leaking, so shortness of breath can occur. Chest pain is pretty uncommon, as is dizziness. That\u2019s much more common for a patient who has aortic valve stenosis. In other words, with the narrowing of the valve, patients may have palpitations from the leaking valve or the big left ventricle. Atrial fibrillation can occur, but that\u2019s also uncommon. That\u2019s more related to the mitral valve.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Is surgery recommended for patients with no symptoms?<\/h2>\n<p>\u201cNow, in patients who don&#8217;t have symptoms, we look for the size of the left ventricle and if the left ventricle is beginning to deteriorate or the lung functions are beginning to deteriorate. If that\u2019s occurring, then we recommend surgery.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Can a patient\u2019s height impact when surgery is recommended?<\/h2>\n<p>\u201cThere&#8217;s also the group of patients who have enlarged aortic root, and particularly in the patients who have a family history of aortic dissection that we will operate on before they develop symptoms or signs of a failing heart. So, one of the formulas we use to recommend surgery is we take the cross-sectional area of the aortic root, divide it by the patient&#8217;s height in meters, and if that ratio is more than 10, then we recommend surgery.\u201d<\/p>\n<p>\u201cThat takes into account the fact that patients who are shorter may, and we\u2019ve shown this, have a higher risk of aortic dissection than somebody who\u2019s tall with an equivalent size aortic root. That comes into the calculation also.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Are there guidelines that indicate the size at which an aortic aneurysm should be operated on?<\/h2>\n<p>\u201cFor most patients, when they get up to about five centimeters or so for the aortic root, we recommend surgery. We\u2019ve also shown in patients with bicuspid valves. The enlarged aortic root is a higher predictor of developing aortic root dissection and problems than the ascending aorta size. Now, if somebody has a family history of aortic dissection and, say, Marfan\u2019s or Loeys-Dietz Disorder or any of the other connective tissue disorders, then we often recommend surgery at a smaller size, and that may be at four or five centimeters.\u201d<\/p>\n<p>\u201cThere is a group of patients we\u2019ve been looking at who have severe aortic valve regurgitation and not particularly enlarged aortic root. In those patients, we found we can successfully repair the aortic valve in a lot of those patients and do a reimplantation operation for them, even though the root is not very big and the results look pretty good long-term.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>What is the likelihood that the aortic valve can be repaired during a Modified David Reimplantation?<\/h2>\n<p>\u201cNow the question sometimes is asked, \u2018What is the likelihood that we can repair and keep a valve by the reimplantation and the modifications we use?\u2019 In about a quarter of the patients we will do repairs on the leaflets at the time of the reimplantation to keep the valve. So, for patients who have a three-leaflet valve, I tell them that mostly, 95 percent or better, we can keep the valve for them unless there are big holes in the leaflets. And that\u2019s unusual that they\u2019re so bad that we cannot keep the valves. Occasionally, there are what we call fenestrations. As long as they\u2019re not too big, we can usually keep the valve.\u201d<\/p>\n<p>\u201cThe other group are patients with calcium at the annulus where the leaflets are attached to the aorta. We generally do not do a reimplantation operation for those patients.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Does age impact candidacy for a Modified David Reimplantation Procedure?<\/h2>\n<p>\u201cI don\u2019t consider age particularly an exclusion,\u201d said Dr. Svensson. \u201cA couple of weeks ago, I had a patient who was 81 years old. She really wanted to keep her valve, and we did a reimplantation operation for her. She did great. Age is not really a factor, and we\u2019ve done kids. Age is not really a strong factor. Certainly, in elderly patients, we often find calcium, so they may not be a candidate for a modified reimplantation procedure.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Which tests help Cleveland Clinic determine if the Modified David Reimplantation Procedure is appropriate for a patient?<\/h2>\n<p>\u201cAs far as whether we can do the operation or not, the echo before surgery is a very good indication, but we can only be sure at the time of surgery, particularly in the patients who have severe leaking valves. Whether that\u2019s due to big holes in the leaflets, or if it\u2019s just from the leaflets being pulled apart by the enlarged annulus or aortic root.\u201d<\/p>\n<p>\u201cThe final decision on whether we can keep and repair a valve is related to what we find at the time of surgery.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>How can patients learn more about the Modified David Reimplantation Procedure?<\/h2>\n<p>\u201cYou\u2019ll see in <a href=\"http:\/\/heartvalvesurgery.com\">HeartValveSurgery.com<\/a> there is a section about the reimplantation operations first described by Tyrone David from Toronto and then also the modification I made many years ago. Most people, I think, are now using modifications of the original operation, and even many of the well-known surgeons who do this operation are now using the modification with the pledgeted sutures and Hegar\u2019s dilators because we think that holds up much better. And it takes away from the complexity of figuring out whether the valve can be preserved or not.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h2>Thanks Dr. Svensson and the Cleveland Clinic!<\/h2>\n<p>On behalf of all the patients at HeartValveSurgery.com, thank you, <a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Lars-Svensson-Cleveland-Ohio.php\">Dr. Svensson<\/a>, for sharing your expansive knowledge and insight about the modified David Reimplantation Procedure. Thank you for everything you and your team are doing at the Heart and Thoracic Institute at the Cleveland Clinic!<\/p>\n<ul>\n<li><a href=\"https:\/\/www.heart-valve-surgery.com\/heart-surgery-blog\/2013\/02\/23\/patient-success-story-david-procedure-dr-lars-svensson\/\">Robert Green: A Patient Success Story of Dr. Lars Svensson<\/a><\/li>\n<li><a href=\"https:\/\/my.clevelandclinic.org\/health\/treatments\/17421-valve-sparing-or-valve-preserving-surgery-reimplantation-surgery\">Valve-Sparing Aortic Root Replacement, Including Modified David Reimplantation Surgery<\/a><\/li>\n<li><a href=\"https:\/\/www.youtube.com\/watch?v=sP-5iEVm6xo\">Valve Reimplantation with Lars Svensson (Video)<\/a><\/li>\n<\/ul>\n<p>Keep on tickin!<br \/>\nAdam<\/p>\n<p>P.S. For the deaf and hard-of-hearing members of our community, I have provided a written transcript this video below.<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"cms.php","meta":{"_acf_changed":false,"footnotes":""},"categories":[6],"class_list":["post-4708","page","type-page","status-publish","hentry","category-aortic-valve-replacement"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages\/4708","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/comments?post=4708"}],"version-history":[{"count":16,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages\/4708\/revisions"}],"predecessor-version":[{"id":4765,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages\/4708\/revisions\/4765"}],"wp:attachment":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/media?parent=4708"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/categories?post=4708"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}