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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
AFRICA
243
Duration of hospital stay was longer in group 1 (average 14.64
±
3.52 days,
p
=
0.007) (Table 4).
On postoperative echocardiography, we observed that degree
of aortic insufficiency was significantly decreased in patients
who had undergone the David V procedure (
p
<
0.001). No
moderate or severe aortic insufficiency was detected (Table 5).
When we compared factors related to mortality rate, age,
hemi-arch replacement as an additional procedure, ascending
aortic diameter and hypothermia were important parameters.
We observed that advanced age (
p
=
0.04), wide ascending
aortic diameter (
p
=
0.04), hypothermia (
p
=
0.001) and hemi-
arch intervention (
p
=
0.01) increased mortality rates (Table 6).
Age (
p
=
0.01), ascending aortic diameter (
p
=
0.02), degree of
hypothermia (
p
<
0.001) and hemi-arch replacement (
p
=
0.001)
were factors that negatively affected ICU stay (Table 6).
We performed mitral reconstruction in four (5.7%) patients,
mitral valve replacement in three (4.3%), atrial septal defect
repair in two (2.9%), radiofrequency ablation in one (1.4%),
hemi-arch replacement in five (7.1%) and coronary artery bypass
grafting (CABG) in eight (11.4%) patients as an additional
procedure, out of a total of 70 patients. In addition to these
findings, aortic cross-clamp and cardiopulmonary bypass time
were significantly longer in patients who underwent CABG as an
additional procedure (
p
<
0.001,
p
=
0.007, respectively).
Discussion
The Bentall de Bono procedure is seen as the gold-standard
surgical choice for the treatment of standard aortic root
aneurysms but because of complications (mortality, morbidity)
related to the use of anticoagulants when mechanical valves
are used, valve-sparing procedures have come into prominence.
When we look at initial and mid-term results of valve-sparing
procedures, there is no doubt that these techniques can be
confidently used for aortic root aneurysms.
1,2,4
An important study on this subject was done by Gaudino
et
al
.
4
in 890 patients, where 289 mechanical valve composite grafts,
421 biological valve composite grafts and 180 valve-sparing
procedures were evaluated. The surgical mortality rate was 0.2%
(none for the valve-sparing procedures).
They observed that length of hospital stay was related to
age, emergency operation, renal function, re-operation, New
York Heart Association class, ejection fraction, and additional
procedures. At five years, follow-up survival was 89.4%. Renal
function, previous myocardial infarction, redo operations and
additional procedures were related to long-term survival. They
observed no significant difference regarding early and long-
term mortality rates between the groups. At five years, the need
for follow-up re-operation was 0% for the mechanical valve
composite grafts, 2.4% for biological valve composite grafts
and 7.3% for valve-sparing procedures.
4
We noticed that valve
durability was of importance in the mechanical valve graft group
in that study.
In our study, older age (
p
=
0.04), wide ascending aortic
diameter (
p
=
0.004), less degree of hypothermia (
p
=
0.001) and
additional hemi-arch replacement (
p
=
0.001) were the parameters
that increased early period mortality rates. Additionally,
advanced age (
p
=
0.01), wide ascending aortic diameter (
p
=
0.02), degree of hypothermia (
p
<
0.001) and additional hemi-
arch replacement (
p
=
0.001) also increased length of ICU stay.
In a recent study, Lamana
et al
.
9
analysed 324 patients, of
whom 263 had undergone mechanical composite valve graft
surgery and 61 valve-sparing root surgery. They observed that
there were no statistically significant differences in short-term
mortality rates (
p
=
0.71), but the long-term mortality rate
was lower in the valve-sparing group (
p
=
0.001). In the same
study, they noticed that bleeding (requiring re-exploration) was
lower in the valve-sparing group and they associated the higher
mortality rate in the composite valve graft group with early
and late-term complications related to bleeding. Additionally,
there were significant differences between the groups in terms of
thromboembolic events in that study.
9
Coselli
et al.
10
studied early and mid-term results of 83
patients (82 re-implantations, one Florida sleeve procedure).
Table 3. Surgical data between groups
Surgical data
Group 1 (
n
=
46) Group 2 (
n
=
24)
p-
value
TPT (min)
134.84
±
86.93
204.39
±
44.7
0.001
ACC (min)
83.11
±
41.64
163.86
±
38.06
<
0.001
TCA (min),
n
(%)
0 (0)
4 (16)
0.004
Hypothermia (°C)
28.21
±
1.57
28.1
±
2.73
0.86
Cannulation side
<
0.001
Axillary,
n
(%)
44 (95.6)
6 (25)
Aortic,
n
(%)
1 (2.2)
17 (70.8)
Brachiocephalic,
n
(%)
0 (0)
1 (4.2)
Femoral,
n
(%)
1 (2.2)
0 (0)
TPT: total perfusion time, ACC: arterial cross-clamping time, TCA: total circu-
latory arrest.
Table 4. Postoperative complications and length
of hospital stay of the two groups
Postoperative complications Group 1 (n
=
46) Group 2 (n
=
24)
p-
value
Bleeding revision,
n
(%)
0 (0)
1 (4.2)
0.34
Respiratory,
n
(%)
2 (4.3)
1 (4.2)
0.73
IABP usage,
n
(%)
1 (2.2)
0 (0)
0.65
Arrhythmias,
n
(%)
4 (8.6)
1 (4.2)
0.004
Mortality,
n
(%)
1 (2.2)
1 (4.2)
0.57
ICU stay (days)
1.85
±
1.02
3.70
±
3.07
0.003
Hospital stay (days)
14.64
±
3.52
12.20
±
8.08
0.007
IABP: intra-aortic balloon pump, ICU: intensive care unit.
Table 5. Pre-operative and postoperative parameters related to aortic
insufficiency in the David V group
Pre-operative AI
(median/min–max)
Postoperative AI
(median/min–max)
p-v
alue
2.5 ( 2–4)
0 (0–2)
<
0.001
AI: aortic insufficiency.
Table 6. Parameters related to mortality and ICU stay
Parameters
Correlation coefficient
p
-value
Parameters related to mortaliy
Age
0.23
0.04
Diameter of ascending aorta
0.35
0.004
Hypothermia
(–) 0.39
0.001
Hemi-arch replacement
0.28
0.01
Parameters related to ICU stay
Age
0.31
0.01
Diameter of ascending aorta
0.29
0.02
Hypothermia
(–) 0.54
<
0.001
Hemi-arch replacement
0.42
0.001
ICU: intensive care unit.