Several non-randomized observational and comparative studies demonstrated excellent clinical outcomes of minimally invasive David procedure in selected patients with comparable perioperative mortality to the conventional technique. To date, elective David procedure with a minimal access technique has been performed in carefully selected patients. We believe that it could be particularly beneficial to provide younger patients (Marfan syndrome, bicuspid AV) with minimally invasive David procedure as it can allow faster recovery with improved cosmesis with excellent outcomes. A decision to perform minimally invasive David procedure should be individualized to each patient and based on the experience of the team. Further large prospective randomized studies with long-term follow-up are still needed to confirm durability of minimal access technique and to investigate whether this technique can be useful for other subgroups of patients (high-risk, need for aortic valve repair).

Ethical approval: Not directly applicable since this is a review paper. The authors confirm that written consent for submission and publication of patient’s intraoperative image has been obtained from the patient in line with COPE guidance.

Author contributions: Davorin Sef: conceptualization, formal analysis, investigation, methodology, validation, resources, writing – original draft, critical revision and approval of the article. Toufan Bahrami, Shahzad G. Raja, Tomislav Klokocovnik: conceptualization, formal analysis, validation, resources, supervision, writing – reviewing and editing.