CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 AFRICA 141 Other V-SARR techniques were excluded. In our centre, all of these operations were performed by a single surgical team. Operations by other surgical teams were excluded from the study. Indications for the modifiedDavidV technique included aortic root aneurysm with or without significant aortic regurgitation (AR), as recommended by the guidelines,10,11 dystrophic AR with annulo-ectasia or acute aortic dissection. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. Electrocardiogram, echocardiogram and BT angiography screening were performed for all patients pre-operatively. If there was a discrepancy in the aortic measurements between the BT angiogram and echocardiography, the BT angiogram measurement was used. A transoesophageal echocardiography (TEE) was performed on all patients at the beginning of the surgery and after the cardiopulmonary bypass (CPB) was ended. Aortic insufficiency (AI) characteristics and aortic dimensions were obtained from intra-operative TEE. For elective operations, detailed pre-operative screening was performed for any underlying chronic diseases. Five patients (10.5%) were operated on urgently due to acute type A aortic dissection (ATAAD). The data obtained from the medical history were included in the data. Intubations lasting more than 24 hours postoperatively or re-entubations were defined as respiratory failure. Acute neurological pathologies, diagnosed with central nervous system imaging, were defined as cerebrovascular events. A concomitant surgical ablation was performed for the patients who had pre-operative atrial fibrillation. In the post-operative period, atrioventricular (A-V) block events requiring only pacemaker implantation were defined as a rhythm disorder. In order to evaluate bleeding complications, the need for massive blood transfusions and mediastinal exploratory surgery was investigated. Early mortality was defined as any death occurring during hospital stay or during the first 30 days after the operation, while any other death was considered as late mortality.12 We used standard straight grafts to reconstruct the root for all patients. Our re-implantation technique was performed with CPB, moderate hypothermia and intermittent antegrade and retrograde cold-blood cardioplegia. In one arch case, antegrade cerebral perfusion was used throughout the period of hypothermic systemic circulatory arrest and deep hypothermia was performed. After starting the CPB, a part of the external aortic root was carefully dissected with electrocautery. An aortic cross-clamp was inserted and cardioplegic arrest of the heart was achieved. A horizontal aortotomy 1 cm above the sinotubular junction (STJ) was performed and the valve was carefully examined. Once the other part of the external aortic root dissection was completed, the aortic sinuses were excised, leaving an average of a 5-mm suture rim and the coronary buttons were prepared. At the end of all three commissures, 4-0 pledgeted prolene sutures were placed to determine the angular position and the height of the commissures. The aortic graft was sized similarly to principles described by Khachatryan et al.13 We used the aortic biological valve-sizer instrument to determine the proximal graft size. The pledgeted commissural sutures were lifted in the vertical position and abutted against the outer surface of the biological valve sizer (Fig. 1). This region corresponds to the imaginary circular STJ. This allows the measurements to be made with the help of the biological valve sizer. We added 4–7 mm to the measured value and this corresponded to the proximal graft size (Fig. 2). This method gave us the advantage of observing the coaptations of the aortic cusps from the circular cavity of the biological valve sizer. The proximal part of the graft was implanted at the ventriculoaortic junction (VAJ) with 10–12 mattress sutures with/without pledgetes and the proximal graft was narrowed in this plane. Subsequently, the aortic cusps were continuously sutured with 5-0 prolene to the inner part of the stretched graft in a vertical position. Coronary buttons were anastomosed to the graft with 6-0 prolene. A graft that was smaller than the proximal graft was chosen as the distal graft. The two grafts were then anastomosed to each other with 4-0 prolene. The proximal graft was also narrowed in this plane. Hence, the pseudo-sinus was created (Fig. 3). Fig. 1. A: Sizing of the sinotubular junction diameter that will result in optimal aortic valve cusp coaptation. B: The diameter of the imagined circle at the level of the synotubular junction is measured and added to this value by 4 to 7 mm for the modified David V procedure. A B
RkJQdWJsaXNoZXIy NDIzNzc=