How I Do It: The Novel Deconstructed David Technique plus Bicuspid Aortic Valve Repair for Asymmetric Valve with Annular Ectasia and Sinking Sinus

J. Putnam, E. E.. Roselli, B. Kramer
Cleveland Clinic, Cleveland, Ohio

Please explain the educational or technical point that this video addresses.: This video serves as a demonstration of the novel deconstructed David technique for aortic valve sparing root replacement. The deconstructed David is a versatile repair strategy that can be tailored to a patient's unique anatomy. Here we apply the deconstructed David to a patient with an aortic root aneurysm, asymmetrical bicuspid valve, annular ectasia, and sinking sinus.

The deconstructed David technique involves the modification of a Valsalva graft into two components: the crown graft and the neoaortic sinuses. These graft components are fitted together to effectively reimplant the aortic valve while reinforcing the valve and LVOT and replacing the sinus roots.

This technique facilitates reduction of awkward needle angles, easier reimplantation of difficult to reach valves, and makes commissural sewing more accessible by allowing approach from the outside.

Please provide a 250 word summary of the surgical video being submitted.: This case involves a patient with a progressively enlarging aortic root aneurysm, asymmetrical bicuspid valve, annular ectasia, and sinking sinus. After agreeing to undergo surgery, the decision was made to use the deconstructed David technique for repair. Upon aortic root exposure, this patient's sinking sinus morphology necessitated deep dissection for ventriculo-aortic junction exposure. The aneurysmal sinuses were resected, leaving a thin rim of aortic tissue over the sinking sinus. The deconstructed David technique is able to overcome a challenge, whereas a Yacoub remodeling procedure could have struggled. A circumferential line of subvalvular sutures is established, and a Valsalva graft is modified to create a "crown graft" which is composed of a subannular ring and palisading segments corresponding to the patient's commissures. The crown graft is descended into position and tied down with the help of a hegar dilator, allowing for appropriate annular sizing. The skirt of the Valsalva graft is then modified to form two neoaortic sinuses accounting for the patient's bicuspid morphology. The crown graft, aortic tissue, and neoaortic sinuses are then sewn together from the outside. This external sewing method is easier to perform than the internal sewing method of a traditional David, epically when very deep dissection is necessary due to a sinking sinus. A new STJ is formed, and ascending aortic homograft is attached, completing the aortic repair. The patient's root pathology was successfully treated, and their outcome was excellent as confirmed by imaging.