CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 144 AFRICA recover. The David V technique, coronary revascularisation and mitral valve repair procedures were performed concomitantly on the second patient. Severe intracranial haemorrhage was seen in the postoperative period and the patient died due to this complication. There was no mortality in patients who were operated on urgently. Postoperative data and complications are presented in Table 3. One patient (2.1%) presented with aortic valve calcification, and concurrent decalcification was performed. This patient had a low diastolic pressure on postoperative day one. Severe AI was observed on TTE and a re-operation was needed in the early stage. Severe leaflet perforation was noticed in the site where decalcification was performed. A mechanical aortic prosthetic valve was implanted inside the existing graft and the patient was discharged nine days later. Four (8.3%) of the patients died in the late stage. The first patient died on postoperative day 61, due to pneumosepsis. The second patient had chronic obstructive pulmonary disease and diabetes mellitus pre-operatively and died due to an unknown reason in the postoperative third month. The third patient died due to massive gastrointestinal bleeding three years after the surgery. The fourth patient’s left ventricular ejection fraction (LVEF) was 35% and the left ventricular end-diastolic diameter (LVEDD) was 7.2 cm pre-operatively. The patient was admitted to another centre with resistant ventricular fibrillation four years after the surgery and died. Only one patient (the third patient) (2.1%) had a major bleeding complication and died because of it. In contrast to that, no thromboembolic events occured in any of our patients. The median follow up for five patients with BAV was 5.3 ± 3.7 years (0.2–9.5) and none died. No aortic stenosis or ≥ 2+ AI was detected in their follow up. A total of six patients died during follow up. One patient needed an AVR procedure in the early period. In other words, procedure failure occured in only one patient who had undergone AVR. Actual survival rate at one year was 91 ± 4% and at 10 years it was 86 ± 5%. The overall survival rate for all patients is shown in Fig. 4. At the end of our follow up, no more than moderate AI was detected in any of the patients. Five (10.4%) of the patients had moderate AI, 13 (27.03%) had mild AI, and 20 (41.6%) had no AI. Freedom from moderate to severe residual AI was 89.6% at 10 years (Fig. 4). None of our patients needed an aortic valvular re-intervention in the late term. Additionally, no deformities were seen in our re-implanted aortic valves. Freedom from valve re-operation was 100% at the end of follow up. Discussion As evident from recent studies, the long-term results of the V-SARR technique are better than composite graft replacements. Despite this, composite graft replacement is still the preferred technique.7,17,18 The reason for this might be that when both techniques are compared, V-SARR (especially the David V) is a multi-stage operation with more parts to be sutured, and it needs precise mathematical measurements. It also needs experienced surgical staff and dedicated cardiac centres. The duration of the operation is also longer and there are few studies on the technique in the literature. Because of this, V-SARR techniques are less popular. Studies need to be conducted at cardiac centres with experienced surgeons and high patient volumes in order to provide more adequate scientific data in order to evaluate V-SARR more effectively. More studies on V-SARR would also allow more cardiac surgeons to acquire experience in these procedures. In the modified David V technique (Stanford modification), two different grafts are used in order to create an artificial neo-sinus.13 The artificial sinus allows the valves to remain durable in the long term. The modified David V technique stands out among other V-SARR techniques because of its known positive effects on aortic valve physiology.19-22 In our case series on the modified David V procedure, no symptomatic AI due to aortic cusp deformity was observed. Hence, none of our patients 1,0 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0,0 Cumulative survival 0 1 2 3 4 5 6 7 8 9 10 Years since surgery N: 48 38 37 34 32 29 26 18 13 7 2 CD: 0 6 7 10 12 15 18 23 29 35 37 AI. (degree) of the patients 0+ 20 24 24 23 21 19 13 7 4 1+ 13 10 7 6 5 5 4 4 2 2+ 4 3 3 3 3 2 2 2 1 3+ 1 0 0 0 0 0 0 0 0 4+ 0 0 0 0 0 0 0 0 0 AI: aortic insufficiency, CD: censored data Fig. 4. Freedom from death and degree of aortic insufficiency of the patients. Table 3. Postoperative data Variables Results LCOS 1 (2.1) CVE 2 (4.2) Respiratory failure 8 (16.7) Bleeding 4 (8.3) Pericardial tamponade 2 (4.2) Sternal dehiscence 3 (6.3) Rythm disorder 1 (2.1) Early repair failure (intra-operative conversion to AVR) 1 (2.1) ICU stay (day ± SD) 2 ± 2 (1–51) Hospital stay (day ± SD) 9 ± 8 (5–51) 30-day mortality 2 (4.3) Values are presented as mean ± standard deviation or frequencies (%). AVR: aortic valve replacement, CVE: cerebrovascular event, ICU: intensive care unit, LCOS: low-cardiac-output syndrome, SD: standard deviation.
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