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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
244
AFRICA
They observed one surgical mortality, one stroke (because of
acute aortic dissection) and intra-operative valve replacement
was performed on one patient. They concluded that valve-
sparing procedures had satisfying early period results.
10
Arabkhani
et al.
11
studied 4 777 patients and 1 659 articles in
a meta-analysis. They compared valve-sparing procedures (72%
re-implantation, 27% remodelling, 1% other procedures) and
indicated that early period mortality rate was 2%, and there were
no statistically significant differences between the procedures in
terms of survival and re-operation. They concluded that valve-
sparing procedures were an alternative to mechanical valve grafts
in terms of survival rate.
11
Patel
et al
.
12
studied 140 patients (56 Bentall de Bono, 84
valve-sparing procedures). They implied that thromboembolic
events were higher in the Bentall group. Additonally eight-year
survival rate was higher in the valve-sparing group.
12
David
et al
.
5
studied 296 patients who underwent
re-implantation procedures. They observed four surgical
deaths and 18 late-term deaths. Five-year survival rate
was 95.1
±
3.5%, 10-year survival was 93.1
±
4.4% and
15-year survival was 76.5
±
18%. They performed mechanical
composite valve grafts on three patients because of severe
aortic insufficiency.
5
Kallenbach
et al
.
13
and Svensson
et al
.
14
showed similar results
in their studies. Parallel to these findings, in our study, there was
no statistically significant difference between the Bentall de Bono
and David V procedures in terms of morbidity and mortality
rates (
p
=
0.57).
Karendi
et al.
15
compared the David procedure (37 patients)
with the Bentall de Bono procedure (73 patients) in high-
risk patients (type A aortic dissections, re-operations). They
indicated that there was no statistically significant difference
between the procedures related to pre-operative and operative
data, except for cross-clamp time.
15
Similar to this, in our study,
CPB time and cross-clamp time were significantly longer in the
David V group but there was no statistically significant difference
in other surgical data between the groups.
In our study there was no statistically significant difference
between the groups in terms of in-hospital mortality rate,
bleeding (requiring re-exploration), thromboembolic events,
respiratory complications and IABP usage. Incidence of cardiac
arrhythmias was higher in the Bentall group (
p
=
0.004). There
were no operative deaths in either group. We lost one patient in
each group because of pneumonia in the early period.
Skripochnik
et al.
16
studied 70 patients (25 valve-sparing,
45 Bentall procedure) and observed no difference between the
groups regarding peri-operative mortality rates. In addition,
there was no significant difference between the groups in terms
of length of hospital and ICU stay.
16
In our study, ICU stay was longer (
p
=
0.003), but hospital
stay was shorter in the David V group (
p
=
0.007). We believe
that long hospital stay for the Bentall group was associated with
warfarin use and dose adjustments, because we routinely follow
patients at in-patient clinics until appropriate INR values are
achieved. In addition, we found that age (
p
=
0.01), diameter of
ascending aorta (
p
=
0.002), hypothermia (
p
<
0.001) and hemi-
arch replacement (
p
=
0.001) had an impact on length of ICU
stay. We believe that longer ICU stay for the David V group was
associated with longer cross-clamp time, longer total perfusion
time (
p
=
0.001) and higher average age (
p
=
0.04).
Conclusion
Although the Bentall de Bono procedure is seen as the gold-
standard surgical approach for aortic root aneurysms, there
are some complications related to this procedure. Because the
native aortic valve is not protected in the dilated aortic root,
physiological superiority of the native valve is lost. In addition,
warfarin use and dose adjustment prolongs hospitay stay.
Many studies have revealed that early, mid- and long-term
results of the Bentall and David V procedures are similar. Since
there was no difference between the two procedures in our
study in terms of morbidity and mortality rates, the biggest
advantage of the David V procedure is that it protects the native
valve. In addition, the David V procedure is safer because there
are no complications related to the use of mechanical valves
and anticoagulants in the postoperative period. Therefore we
propose use of the David V procedure primarily for patients with
dilated aortic root and/or dilated ascending aorta with normal
aortic valves.
References
1.
David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles
of repair and long-term follow-up.
J Thorac Cardiovasc Surg
2010;
140
:
14–19.
2.
Silva VF, Real DS, Branco JN, Catani R, Kim HC, Buffolo E,
et al.
Bentall and De Bono surgery for correction of valve and ascending
aortic disease: long-term results.
Rev Bras Cir Cardiovasc
2008;
23
:
256–261.
3.
David TE, Feindel CM, Webb GD, Colman JM, Armstrong S, Maganti
MD. Aortic valve preservation in patients with aortic root aneurysm:
results of the reimplantation technique.
Ann Thorac Surg
2007;
83
:
732–735.
4.
GaudinoM, Lau C, Munjal M, Avgerinos D, Girardi LN. Contemporary
outcomes of surgery for aortc root aneurysms: A propensity-matched
comprasion of valve-sparing and composite valve graft replacement.
J
Thorac Cardiovasc Surg
2015;
150
: 1120–1129.
5.
David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles
of repair and long-term follow-up.
J Thorac Cardiovasc Surg
2010;
140
:
14–19.
6.
Bentall H, de Bono A. A technique for complete replacement of the
ascending aorta.
Thorax
l968;
23
: 338–338.
7.
Yakut C. A new modified Bentall procedure: the flanged technique.
Ann
Thorac Surg
2001;
71
: 2050–2052.
8.
David TE, Feindel CM. An aortic valve-sparing operation for patients
with aortic incompetence and aneurysm of the ascending aorta.
J
Thorac Cardiovasc Surg
1992;
103
: 617–621.
9.
Lamana F de A, Dias RR, Duncan JA, Faria LB, Malbouisson LM,
Borges L de F,
et al
. Surgery of the aortic root: should we go for the
valve-sparing root reconstruction or the composite graft valve replace-
ment is still the first choice of treatment for these patients?
Rev Bras Cir
Cardiovasc
2015;
30
: 343–352.
10. Coselli JS, Hughes MS, Green SY, Price MD, Zarda S, de la Cruz KI,
et
al
. Valve-sparing aortic root replacement: Early and midterm outcomes
in 83 patients.
Ann Thorac Surg
2014;
97
: 1267–1274.
11. Arabkhani B, Mookhoek A, Di Centa I, Lansac E, Bekkers JA, De Lind
van Wijngaarden R,
et al
. Reported outcame after valve-sparing aortic
root replacement for aortic root aneurysm: A systematic review and
meta-analysis.
Ann Thorac Surg
2015;
100
: 1126–1131.
12. Patel ND, Weiss ES, Alejo DE, Nwakanma LU, Williams JA, Dietz
HC,
et al
. Aortic root operations for Marfan syndrome: A comparison