Medline, EMBASE databases, and the Cochrane Library were searched from
1992 (date of first David procedure performed) to December 2021 by a
librarian. Eligible studies were identified using various combinations
of Medical Subject Headings and keywords in the abstract or title:
valve-sparing aortic root replacement, David procedure, minimally
invasive cardiac surgery, (upper) hemisternotomy. Seven retrospective
nonrandomized studies from 6 different centers were identified including
a total of 283 patients operated via minimal access. Ethics Committee
approval was not required as this is a review manuscript. Case reports,
conference papers or abstracts and studies not published in languages
other than English were excluded.
Patient selection and preoperative assessment
Recent evidence demonstrates that patient selection plays important role
in the long-term outcomes of the David procedure in both conventional
and minimally invasive approach.5, 10, 13 Several
centers reported how they started performing minimally invasive David
procedure in carefully selected elective patients after having
experience in performing David procedure via conventional
sternotomy.10-13,15 In addition, a few studies
emphasized the importance of developing fundamental skillset and having
experience in minimally invasive AVR beforehand due to the challenges of
the learning-curve.10,11,13
Shrestha and colleagues reported that they have initially performed
minimally invasive David procedure in relatively young patients
(<60 years) with isolated aortic root aneurysm, no significant
co-morbidities, and AR without leaflet
calcifications.10 Furthermore, excellent initial
outcomes have encouraged performing minimally invasive David procedure
in all elective patients with isolated aortic root
aneurysm.13 However, this approach was generally not
considered in patients with previous sternotomy and those requiring
additional concomitant procedures (coronary bypass, valve
surgery).10 A very deep aortic root might represent an
anatomical contraindication for minimally invasive approach. Still, the
final decision whether to proceed with a valve-sparing technique was
made by the surgeon intraoperatively after the assessment of AV using
transesophageal echocardiography (TOE) and direct
inspection.10,13,24
Preoperative work-up is another important aspect for performing
minimally invasive David procedure safely.10,13 In
addition to routine preoperative assessment, echocardiography, computed
tomography scan of aorta and coronary angiography (age >40
years) are required.10,13,24