Valve-Sparing Aortic Root Replacements: David Procedure and the Florida Sleeve
Key takeaways
Valve-sparing aortic root replacement is a highly specialized category of open-heart surgery that repairs a life-threatening bulge at the base of the aorta while saving the patient's natural aortic valve.
An aortic root aneurysm is an abnormal swelling at the base of the body's main artery. As it expands, it stretches the aortic valve out of shape. This causes blood to leak backward into the heart.
By preserving your natural valve, you avoid the risks of an artificial mechanical valve, most notably the requirement to take lifelong, high-risk blood-thinning medications.
The two leading valve-saving techniques are the David procedure, which involves cutting out the root and stitching the valve inside a synthetic tube and the Florida sleeve, in which the surgeon wraps a protective fabric sleeve around the existing root.
UF Health surgeons invented and perfected the Florida sleeve procedure. Long-term clinical studies show excellent durability and valve function. This is even true in high-risk patients with genetic conditions such as Marfan syndrome.
What is an aortic root aneurysm?
The aorta is the main pipeline that carries oxygen-rich blood from your heart to your body. The very beginning of this pipeline connects directly to your heart's main pumping chamber. This specific section is called the aortic root.
Inside this root sits the aortic valve. Think of this valve as a one-way gate with three delicate flaps or leaflets. These flaps open wide to let blood pump out, then snap shut to keep it from flowing backward.
Sometimes, the walls of the aortic root weaken. When this happens, blood pressure forces the root to balloon outward. This bulge is an aortic root aneurysm. As the root stretches, it pulls the flaps of your heart valve apart. Because the flaps can no longer meet in the middle to close tightly, blood leaks backward into the heart. Doctors call this leak aortic valve regurgitation or aortic insufficiency.
If left untreated, an aortic root aneurysm can burst or tear. A tear is called an aortic dissection and it is a life-threatening medical emergency. In the past, fixing this meant replacing both the aorta and the valve with artificial parts. Today, advanced valve-sparing techniques allow surgeons to fix the artery and save your natural valve.
What conditions does The Florida Sleeve and David Procedure treat?
Surgeons use valve-sparing root replacements for patients with a dangerous bulge at the base of the heart who still have healthy valve flaps. These procedures treat:
Aortic Root Aneurysms: Long-term swelling at the very base of the aorta.
Severe Aortic Regurgitation: Heavy backward blood leaking caused entirely by a stretched aortic wall.
Genetic Connective Tissue Disorders: Conditions passed down through families that weaken artery walls. These include Marfan syndrome, Loeys-Dietz syndrome and Ehlers-Danlos syndrome.
Bicuspid Aortic Valve Disease: A condition a patient is born with where the aortic valve has only two flaps instead of three. This issue often causes early root aneurysms.
Symptoms to look out for
Like many blood vessel problems, aortic root aneurysms usually grow silently. They can develop over several years without causing any symptoms at all. Doctors often find them by accident during a routine chest X-ray, CT scan or heart ultrasound (echocardiogram) done for another reason.
However, as the bulge grows larger or the valve leak gets worse, you may notice symptoms like:
A constant, deep, throbbing pain in your chest or upper back.
Shortness of breath, especially when you exercise or try to lie flat in bed.
Heart palpitations, which feel like your heart is racing, skipping beats or pounding hard.
Severe fatigue or dizziness because your heart is working less efficiently.
Note: If you experience sudden, severe chest or back pain that feels like a ripping or tearing sensation, call 911 immediately. This is a sign of an aortic emergency.
Who can get a valve-sparing procedure?
Not every patient with an aortic aneurysm can have a valve-sparing surgery. To be a good candidate, your heart must meet a few specific conditions:
Healthy Valve Leaflets: The physical leaflets of your valve must be clean, flexible and free of disease. If your valve is heavily scarred, hardened with calcium or damaged by a bacterial infection (endocarditis), it cannot be saved and must be replaced.
The Right Timing: Surgeons usually recommend surgery when a root aneurysm grows to 5 to 5.5 centimeters wide. For patients with genetic conditions like Marfan syndrome, surgeons often operate sooner—at 4.5 to 5 centimeters—to prevent a tear before it happens.
Good General Health: This is an open-heart surgery that requires a heart-lung bypass machine. Patients must be strong enough to safely undergo the operation and the recovery process.
Valve-sparing surgical options
If you have a valve-sparing aortic root replacement, your surgical team will use one of two advanced techniques to stabilize your artery and fix your valve:
The David Procedure (Reimplantation)
Developed by Dr. Tirone David, this technique is a highly precise reconstructive surgery. The surgeon opens your chest, stops your heart and cuts away the diseased, ballooned root tissue. They are very careful to leave your healthy valve flaps completely intact.
Next, the surgeon takes a tube graft made of a strong fabric called Dacron. They place your natural valve flaps directly inside this fabric tube and stitch them securely into place. Finally, the surgeon must cut your coronary arteries (the blood vessels that feed your heart muscle) away from the old aorta and sew them into tiny holes cut into the new fabric tube.
The Florida Sleeve Procedure (reimplantation)
The David Procedure works well, but it is highly complex. It requires a long time on the heart-lung bypass machine and carries a risk of surgical bleeding. To solve these problems, surgeons at UF Health invented the Florida Sleeve procedure.
Instead of cutting out the entire aortic root and disconnecting your coronary arteries, the Florida Sleeve leaves your original tissue completely alone. The surgeon takes a custom fabric sleeve and slides it right over the outside of your ballooned aortic root.
The surgeon makes small, precise slits in the fabric so your coronary arteries can stick through naturally. Then, they anchor the sleeve firmly at the base. The sleeve acts like a tight corset. It instantly shrinks the stretched aorta back to a normal size and pushes your leaking valve flaps back together so they can seal perfectly again.
Invented at UF Health: The Florida Sleeve story
UF Health is the proud birthplace of the Florida Sleeve. It was developed over 20 years ago by a team led by Tomas Martin, MD, a professor of surgery and associate director of the UF Health Aortic Disease Center. The team created this technique to make valve-saving surgery simpler, safer and more widely available.
Dr. Martin notes that surgeons worldwide use the Florida Sleeve because it protects the patient's natural anatomy. Because surgeons do not have to cut and reattach the delicate coronary arteries, the operation goes much faster. This means less time on the bypass machine and a much lower risk of bleeding or stroke after surgery.
Proven long-term success
For years, some doctors worried that wrapping an aneurysm from the outside might not hold up over time. They were especially concerned about patients with Marfan syndrome, who naturally have very weak tissue.
A major clinical study by the UF Health team proved that the Florida Sleeve is highly durable. The Florida Sleeve is now recognized as a top-tier, highly durable standard of care that saves natural heart valves for life.
Frequently asked questions
Why is keeping my natural aortic valve better than getting an artificial one?
If you get an artificial mechanical valve, you must take a powerful blood-thinning medication (like Warfarin) every day for the rest of your life to prevent blood clots. Blood thinners require regular blood tests and limit your diet and activities due to bleeding risks. Keeping your natural valve avoids blood thinners completely, lowers your long-term risk of heart infections and keeps your natural heart rhythm.
How do doctors choose between the David Procedure and the Florida Sleeve?
Both surgeries save your valve and fix the weak root. The David Procedure is an excellent, time-tested option, but it requires cutting out your coronary arteries and completely rebuilding the aortic root. The Florida Sleeve is often preferred because it leaves your native tissue in place and simply wraps it from the outside. This makes the surgery simpler, faster and reduces the risk of bleeding.
What is the recovery time after a valve-sparing root replacement?
Both aortic valve repair procedures are major open-heart surgeries. You will typically spend 5 to 7 days recovering in the hospital, including your first night in the cardiovascular intensive care unit (CVICU). Once you go home, full recovery takes about 6 to 8 weeks. During this time, you cannot lift anything heavy while your breastbone heals.
Can an aortic valve-sparing root replacement fail later in life?
The synthetic fabric sleeve or tube graft will never stretch or wear out. However, your natural valve flaps inside it are made of living tissue. Over several decades, those flaps can still experience normal aging or calcium buildup. Even so, UF Health's long-term data shows that the vast majority of patients enjoy excellent, stable valve function for many years without ever needing another aortic valve surgery.
Why choose the UF Health Aortic Disease Center?
The UF Health Aortic Disease Center is a world-class leader in complex aortic root surgery and valve repairs. As the birthplace and national home of the Florida Sleeve, our surgeons have unmatched, firsthand experience performing and perfecting this technique. Our care model brings together a team of different specialists—including cardiothoracic surgeons, geneticists, advanced imaging specialists and dedicated intensive care unit providers. Because we are a high-volume academic research hospital, we routinely achieve exceptional survival rates and valve-preservation success for complex cases that smaller regional hospitals simply cannot treat.
To learn more about our pioneering valve-sparing surgeries or to schedule a full evaluation, please contact the UF Health Aortic Disease Center by calling (352) 273-5494.
This entry was written by Gabrielle Massari, Marketing Content Writer, and reviewed for accuracy by Eric Jeng, MD. Generative AI was leveraged as part of the content creation process.