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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
242
AFRICA
Methods
We operated on 70 patients (flanged Bentall de Bono: 46, David
V: 24) for aortic root aneurysm in our hospital between April 2009
and June 2013. Data were evaluated retrospectively. Patients were
divided into two groups according to the procedure. Patients who
had the flanged Bentall de Bono procedure were in group 1, and
those who had the David V procedure were in group 2.
All patients were intubated under general anaesthesia and
they were on mechanical ventilation during the operation. A right
jugular central venous catheter was inserted routinely. A standard
median sternotomy was performed and cardiopulmonary
bypass was instituted. The venous line was inserted through
the right atrial appendage generally, but selective bicaval venous
cannulation was performed in some cases. Myocardial protection
was achieved by cardioplegia, specifically by intermittent
antegrade or simultaneous antegrade and retrograde (66.5%)
administration of hypothermic blood cardioplegia, according
to the decision of the surgeon. A venting cannula was inserted
through the right superior pulmonary vein.
In group 1 we performed a modified version of the Bentall
procedure, called a flanged Bentall. In this procedure, the
ascending aorta is resected and the coronary ostia are prepared
as buttons. Then the aortic root and valve is resected. A
mechanical aortic valve is sutured to the composite graft, leaving
a part of the proximal side everted outwards (flange). This is
done with continuous polyprolene sutures from the stent of the
valve to the graft. The conduit is sutured to the aortic annulus
with polyprolene sutures from the flanged part. After this, the
coronary buttons are sutured to the graft. The distal part of the
graft is then sutured to the distal aorta with teflon felt.
In group 2, a routine transverse aortotomy was done about
2 cm above the coronary ostia. If it was clear that there was no
structural pathology on the aortic valve, the ascending aorta was
resected, keeping 5 mm of aortic tissue on the aortic annulus.
Thereafter the standard David V procedure was performed.
Statistical analysis
Statistical analyses were performed using SPSS version 15.0
software. Compliance with the normal distribution of variables
was evaluated with visual (histogram and probability graphics)
and analytical methods (Kolmogorov–Simirnov/Shapiro–Wilk
tests). Descriptive analysis was done using frequency tables
for categorical variables and means and standard deviations
for normally distributed variables. We used the median and
25th and 75th quartiles for analysis of variables without a
normal distribution. To compare the groups, we performed an
independent samples
t-
test for variables with normal distribution,
and the Mann–Whitney
U-
test for those without a normal
distribution. We also performed Pearson’s chi-squared test (
χ
2
)
for categorical variables;
p
<
0.05 was considered as significant.
Results
The mean age of the patients was 52.01
±
16.82 years, and 52
(74.3%) were male and 18 (25.7%) were female. There were
statistically significant differences between the groups in terms
of age and having coronary artery disease (
p
=
0.04 and
p
<
0.001, respectively). Demographic features of the groups are
summarised in Table 1.
When we compared the pre-operative echocardiographic
findings, there was a statistically significant difference in the
aortic annulus diameter between the groups (
p
=
0.03). Mean
aortic annulus diameter was 3.30
±
1.32 cm in group 1 and 2.76
±
0.41 cm in group 2. Mean ascending aorta diameter was 5.49
±
1.18 cm in group 1 and 5.73
±
0.99 cm in group 2 (
p
=
0.39).
There was no significant difference in terms of degree of aortic
insufficiency between the groups (
p
> 0.05) (Table 2).
When we compared surgical data (Table 3), average
cardiopulmonary bypass time was 69.55 min shorter in group
1 (
p
=
0.001, 95% CI: 108.19–30.90 min). Average arterial cross-
clamp time was 80.75 min shorter in group 1 (
p
<
0.001, CI:
101.55–59.95 min).
With regard to postoperative complications, postoperative
arrhythmias were seen in four (8.6 %) and one (4.2%) patient in
groups 1 and 2, respectively (
p
=
0.004). There was no statistically
significant difference between the groups in terms of respiratory
complications, bleeding requiring re-exploration, and intra-
aortic balloon pump (IABP) usage. No stroke was observed in
either group.
We lost one patient in each group and there was no statistically
significant difference between the groups in terms of mortality
rate. ICU stay was shorter in group 1. Average ICU stay was 1.85
±
1.02 days in group 1 and 3.70
±
3.07 days in group 2 (
p
=
0.003).
Table 1. Demographic data of the two groups
Demographics
Group 1
(
n
=
46)
Group 2
(
n
=
24)
p-
value
Age
50.04
±
18.05 58.70
±
12.67 0.04
Male gender,
n
(%)
35 (76)
17 (70.8)
0.63
COPD,
n
(%)
16 (34.7)
10 (41.6)
0.57
Smoking,
n
(%)
14 (30.4)
12 (50)
0.10
Hypertension,
n
(%)
26 (56.5)
18 (75)
0.12
Diabetes mellitus,
n
(%)
15 (32.6)
6 (25)
0.51
Coronary artery disease,
n
(%)
2 (4.3)
9 (37.5)
<
0.001
Peripheral vascular disease,
n
(%)
2 (4.3)
0 (0)
0.54
NYHA class 1,
n
(%)
8 (17.3)
4 (16.6)
<
0.06
NYHA class 2,
n
(%)
12 (26.08)
7 (29.1)
NYHA class 3,
n
(%)
14 (30.4)
7 (29.1)
NYHA class 4,
n
(%)
12 (26.08)
6 (25)
COPD: chronic obstructive pulmonary diesase, NYHA: New York Heart Asso-
ciation.
Table 2. Pre-operative echocardiographic findings
Pre-operative echo findings
Group 1 (
n
=
46) Group 2(
n
=
24)
p-
value
Ascending aorta diameter
5.49
±
1.18
5.73
±
0.99
0.39
Aortic annulus diameter
3.30
±
1.32
2.76
±
0.41
0.03
Sinus of Valsalva diameter
5.16
±
1.17
5.08
±
0.69
0.79
EF (%)
60.85
±
7.4
57.50
±
10.57
0.42
LVESD (cm)
3.74
±
1.04
5.45
±
7.8
0.17
LVEDD (cm)
5.43
±
1.06
7.98
±
11.59
0.16
IVS (cm)
1.25
±
0.19
1.11
±
0.12
0.50
AI,
n
(%)
31 (67.3)
19 (79.1)
0.30
AI degree
0.13
1,
n
(%)
7 (15.2)
0 (0)
2,
n
(%)
11 (23.9)
10 (41.6)
3,
n
(%)
4 (8.6)
4 (16.6)
4
9 (19.5)
5 (20.8)
Echo: echocardiography, EF: ejection fraction, LVESD: left ventricular end-
systolic diameter, LVEDD: left ventricular end-diastolic diameter, IVS: inter-
ventricular septum, AI: aortic insufficiency, cm: centimetre.