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Incidence and Progression of Mild Aortic Regurgitation after the David I Procedure
Fabian A. Kari1, Sami Kueri1, Bartosz Rylski1, Maximilian Russe2, Matthias Siepe1, Friedhelm Beyersdorf1.
1Heart Center, University of Freiburg, Freiburg, Germany, 2University of Freiburg, Freiburg, Germany.

Objective Mild aortic regurgitation (AR) and progression of AR might be a significant hazard after David I valve-sparing aortic root replacement (V-SARR), potentially resulting in reoperation. Methods Between 2003 and 2013, n=167 patients (n=116 male, age 47±19 years) underwent the David I procedure (n=157 aortic root and/or ascending aortic aneurysm, n=10 Type A dissection, n=53 Marfan). Mid-term follow-up TEE (mean 449 days, 74 - 1427 days) was analyzed. Median preoperative AR was 1+ to 2+, n=58 patients (35%) had preoperative AI ≤ 1+ and n=12 patients (12%) preoperative AR ≥ 3+, while no patients with AR >3+ were elected for David procedure. Uni- and multivariate analysis and LogRank tests were calculated. Valvular endpoints were freedom from AR 2+, freedom from AR 1+ and freedom from new AR or AR progression. Results AR was reduced from a preoperative median of 1-2+ to a median of 0-1+ before discharge (p<0.001). Freedom from AR 2+ was 78% and from AR progression 60% at 2 years. Most patients progressed subclinically from no to trivial or minimal AR. Severe AR > 3+ occurred in 4 patients, leading to reoperation and mechanical valve replacement in three cases. Aneurysm size and aortic downsizing were not linked to higher incidence of mild AR (all p>0.05). Conclusions The incidence of subclinical, progressing AR is significant after the David procedure. While higher grade AR results in the need of reoperation almost invariably, the role of subclinically progressing low grade AR has to be characterized in future follow-up studies.

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