There is little evidence comparing the effectiveness of valve-sparing aortic root replacement with the David procedure and replacement with a composite graft (Bentall procedure) for patients with bicuspid aortic valves (BAV). This systematic review and meta-analysis compared the overall survival and the freedom from re-intervention in BAV patients who underwent root replacement with either the David or Bentall procedure.

Two databases were searched for studies including BAV patients who underwent either the David or Bentall operation. This review was performed in accordance with the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement. One-stage and two-stage meta-analyses were conducted with Kaplan–Meier-derived individual patient data and a random-effects model.

Thirteen studies were included, providing data about 1,264 BAV patients who underwent a Bentall procedure and 602 patients who underwent a David procedure. During a follow-up period of 8 years, overall survival rates were significantly improved in the David group compared with the Bentall group (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.08–0.42; p<0.001). This was confirmed by the two-stage meta-analysis (HR 0.22, 95% CI 0.09–0.55; p=0.00, I²=0.00%). Regarding freedom from re-intervention, splitting timepoint analysis revealed that no arm offered a statistically significant advantage (HR 1.24, 95% CI 0.58–2.63; p=0.575). Finally, the David operation was associated with fewer postoperative complications.

The David operation is associated with improved survival and lower complication rates than the Bentall procedure for patients with BAV. However, freedom from re-operation rates were comparable between the two procedures.