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Bentall Operation: Early Surgical Results, Seven-Year Outcomes, and Risk Factors Analysis

Paolo nardi.

1 Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy

Calogera Pisano

Carlo bassano, fabio bertoldo, alessandro cristian salvati, dario buioni, daniele trombetti, mattia scognamiglio, claudia altieri.

2 Cardiology Unit of the Cardiac Surgery Division, Tor Vergata University Hospital, Tor Vergata University, 00133 Rome, Italy

Giovanni Ruvolo

Associated data.

Surgical and Clinical Data Base of the Tor Vergata University Hospital. Echocardiography data acquisition and interpretation: C.A.

Aim: To analyze early and mid-term outcomes of the Bentall operation. Methods: Two hundred and seventeen patients (mean age 65.6 ± 15.9 years, males/females 172/45) underwent Bentall operation in a 7-year period (January 2015–December 2021), on average, 30 Bentall operations occurred per year, using biological (n = 104) or mechanical (n = 113) valved conduits for the treatment of ascending aorta–aortic root aneurysms. Associate procedures were performed in 58 patients (26.7%); coronary artery bypass grafting (CABG) in 35 (16%). Mean follow-up was 55.2 ± 24 (median 60.2) months. Cox model analysis was used to assess risk factors, Kaplan–Meier and log-rank tests were used to assess different survival rates. Results: Operative mortality was 1.38%. At 7 years, survival, freedom from cardiac death, and event-free survival were 93% ± 2%, 99% ± 1%, and 81% ± 5%. NYHA class ( p < 0.0001), trans-aortic valve mean ( p < 0.0001) and maximum ( p < 0.000) gradients, left ventricular hypertrophy ( p < 0.05), and pulmonary arterial pressure ( p = 0.002) significantly improved vs. preoperative values. Concomitant CABG during Bentall operation independently affected late outcomes (HR 1.9–2.3; p -values < 0.05). Late survival was affected by concomitant CABG (84% ± 8% vs. 95% ± 2%, p = 0.04), preoperative myocardial infarction (91% ± 9% vs. 97% ± 2%, p = 0.02), and biological vs. mechanical prostheses valved conduits (91% ± 9% vs. 95% ± 3%, p = 0.02). Event-free survival also was affected by concomitant CABG (62% ± 14% vs. 85% ± 5%, p = 0.005) and biological prostheses (78% ± 8% vs. 84% ± 6%, p = 0.06). Freedom from endocarditis–redo operation was 83% ± 9% for biological prostheses vs. 89% ± 6% for mechanical prostheses ( p = 0.49). Conclusions: Low rates of operative mortality and late complications make Bentall operation the gold standard for the treatment of ascending aorta–aortic root aneurysms. Coronary ischemic disease affects late outcomes. Biological prostheses should be preferred for the elderly.

1. Introduction

Surgical treatment of ascending aortic aneurysms is still considered a complex at-risk procedure. When the aortic root is involved, Bentall–De Bono operation, initially described in 1968 [ 1 ], is the most performed operation. During the years, this procedure underwent important modifications, including the abandonment of the wrap-inclusion technique in favor of the coronary-button technique, and it has become a widely adopted standard of treatment of various root pathologies. In fact, although valve-sparing procedures are often the preferred approach in selected cases, Bentall operation remains universally applicable in an all-comer cohort and is not limited to favorable valve morphology, including patients at high risk of aortic complications, i.e., genetic family syndromes, bicuspid valve, altered root geometry, coronary ostia dislocation. The complete aortic root replacement can be performed using biological or mechanical valved conduits [ 2 , 3 , 4 ].

Even in experienced hands, the perioperative mortality remains not insignificant. In recent years, groups focused on aortic disease have reported 4–5% mortality rate, a not-negligible incidence of bleeding, and major cardiac and noncardiac postoperative complications, so much so that it has been proposed to define a risk score, already present for coronary and valve surgery, for surgical procedures for the treatment of ascending aorta aneurysms as well [ 2 , 3 , 5 ].

Furthermore, different study groups have focused on Bentall follow-up results with the use of mechanical and biological prostheses, taking into account that for mechanical prosthesis the main problem is the lifelong need for anticoagulant therapy, while the main benefit is the durability, and for biological prosthesis, the main problem is represented by the structural deterioration over time.

The aim of our study was to evaluate early and mid-term results of the modified Bentall operation in accordance with the routinely used coronary “button technique”, also focusing the analysis on surgical technical aspects that could improve early outcomes, especially by reducing postoperative complications, i.e., early postoperative bleeding, or the incidence of development of pseudoaneurysms due to coronary ostia stretch. We reviewed the results of both isolated and more complex Bentall operations, in particular, those associated with coronary artery bypass grafting. We also investigated the risk factors and the impact of the use of biological or mechanical prosthesis valved conduits on seven-year follow-up outcomes.

2. Materials and Methods

2.1. patients and methods.

From January 2015 to December 2021, at the Cardiac Surgery Division of the Tor Vergata University Hospital, two hundred and seventeen patients (172 males, 45 females; mean age 65.6 ± 15.9 years) out of 238 (91%) elective procedures performed to treat ascending aorta expansive aneurysms underwent Bentall operation, with an average of 30 Bentall operations per year. The average percentage value of the EuroScore-2 was 5.0% ± 3.8%. Main surgical indication was performed for expansive ascending aorta (mean diameter 50.0 ± 7.3 mm) and aortic root (mean diameter 44.5 ± 6.6 mm) aneurysms. Moderate to severe degree of aortic valve insufficiency or steno-insufficiency was present in 124 patients (57%). One hundred and sixteen patients (53.5%) had tricuspid aortic valve, 87 (40%) bicuspid valve, and 14 (6.5%) were affected by genetic syndromes (Marfan syndrome, 13 patients; Loeys–Dietz syndrome, 1 case). Associated procedures, including coronary artery bypass grafting (CABG), mitral and tricuspid valve surgery, closure of the foramen ovale patency or atrial septal defect, and aortic arch repair, were performed in 58 patients (26.7%); of them, concomitant CABG was the most frequently performed associated procedure (n = 35, 16%). In the same period of surgical activity, 67 patients underwent emergency Bentall operation for acute aortic syndrome (n = 64) and for acute endocarditis in heart failure phase (n = 3). This group of patients was excluded from our study.

Surgical indications for the treatment of ascending aortic aneurysms were based on the anatomic, clinical, and etiological criteria, and on intraoperative findings, i.e., significant coronary ostia dislocation, aortic wall thickness, evidence of cardiac muscle in transparency at the level of right or noncoronary sinuses, and asymmetric dilation of valsalva sinus/sinuses.

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Independent Ethics Committee of the Tor Vergata University Polyclinic (237.22). All patients gave their informed surgical consent. The study was designed to be a retrospective one.

2.2. Data Analysis

Data analysis included patient history with major cardiovascular risk factors: hypertension, dyslipidemia, smoking, diabetes, obesity, ischemic heart disease, atrial fibrillation, and physical examination, with evaluation of pre- and postoperative echocardiographic parameters. Operative mortality included death in hospital after operation at any time, or within 30 days after discharge. We also investigated the incidence of postoperative low cardiac output syndrome combined with acute kidney injury, the incidence of postoperative noncardiac complications, need for early surgical revision for bleeding, and permanent pacemaker implantation.

Follow-up was obtained by reviewing the medical record and telephone interview with patients on clinical conditions, NYHA functional class, management of INR, on complications arising during follow-up, and on echocardiographic reports. Mean duration of the follow-up was 55.2 ± 24 (median 60.2) months after surgery. Adverse events were classified according to the definitions established by the Society of Thoracic Surgeons and the American Association for Thoracic Surgery “ Guidelines for reporting morbidity and mortality and cardiac valve interventions ” [ 6 ]. Follow-up was closed on July 2022, and was 99% complete; two patients were lost.

2.3. Surgical Treatment

Surgery was performed through full sternotomy in all cases. Once cardiopulmonary bypass was started, after ascending aorta cross-clamping at the level of the proximal region of the arch immediately upstream of the origin of the anonymous trunk, cardiac arrest was achieved using antegrade intermittent warm blood cardioplegia or St. Thomas cold crystalloid solution [ 7 ]. Modified Bentall operation was performed using composite graft valved conduits with mechanical prostheses (n = 113) (Abbott St. Jude Medical Inc., St. Paul, MN, USA, CarboSeal, CarboMedics Inc., Austin, TX, USA; Corcym) or using a tubular cylinder graft (Intervascular, Datascope Corp., Wayne, NJ, USA) sutured to the biological prostheses (Perimount Carpentier, St. Jude Trifecta) (n = 104). Surgical technique consisted of proximal implantation of prosthetic valved conduit, reimplantation of the left coronary ostium, distal aortic anastomosis with Teflon reinforcement, and reimplantation of the right coronary ostium. The coronary ostia were reimplanted with the “button technique” using a 5-0 polypropylene suture. In the presence of a thinned coronary ostia wall, the suture of the left and right coronary ostium to the cylindrical prosthesis was reinforced in the perianastomotic site with a small strip of Teflon. Particular care was taken during the suturing of the coronary ostia on the tubular prosthesis and during the distal suture on the aortic wall, developing the correct tension of the polypropylene thread, using a hook and gently pulling the thread.

2.4. Statistical Analysis

Statistical analysis was performed with the use of Stat View 4.5 (SAS Institute Inc., Abacus Concepts, Berkeley, CA, USA). All continuous values were expressed as mean plus or minus one standard deviation of the mean. The chi-squared or the Fisher’s exact test for categorical variables and the unpaired Student’s t -test for continuous variables were calculated to perform the univariate analysis to detect potential risk factors related with in-hospital mortality and cardiac complications, i.e., low cardiac output syndrome and acute kidney injury. Variables with a p -value less than 0.1 were included in the multivariate logistic regression analysis. Preoperative analyzed variables were sex, age, New York Heart Association class, body mass index, body surface area, rhythm, associated morbidity, i.e., arterial hypertension, smoking habit, dyslipidemia, diabetes mellitus, obstructive pulmonary disease, peripheral vascular disease, increased serum creatinine level, presence of aortic valve stenosis and/or insufficiency, dimension of expansive aortic aneurysm, and presence of ischemic heart disease, i.e., previous myocardial infarction. Echocardiographic variables measured were left ventricular ejection fraction, end-systolic and end-diastolic diameters, left atrium size, septum and posterior wall thickness, and systolic pulmonary artery pressure. Perioperative variables included the mean duration of cardiopulmonary bypass and aortic cross-clamp time, type of heart prostheses valve implanted, i.e., mechanical versus biological, and combined procedures, in particular CABG.

Late survival, event-free survival, and freedom from late cardiac death and from prosthetic valve-related events were calculated by the use of the Kaplan–Meier method; all measurements were expressed as mean values of percentage plus or minus 1 SD. The Mantel–Cox test was used to compare the curves of freedom from events, i.e., in patients who had undergone isolated Bentall operation versus Bentall plus CABG operation, and in those who had undergone mechanical versus biological prostheses implantation. The Cox proportional hazards method was used to estimate the influence of the analyzed variables on time to death. Echocardiographic variables obtained in the postoperative period and during the follow-up were compared with the preoperative ones. p -value of less than 0.05 was considered significant in all types of performed statistical analyses.

Patients affected by ascending aorta aneurysms with a tricuspid aortic valve were older (70 ± 14 years) in comparison to those with a bicuspid aortic valve (64 ± 14 years) ( p = 0.004) or affected by genetic syndromes (40.5 ± 14 years) ( p < 0.0001). The mean age of implantation of valved conduits with mechanical prostheses was 56.7 ± 14.4 years, and the mean age of implantation of valved conduits with biological prostheses was 76.1 ± 10.0 years ( p < 0.0001). As expected, cardiopulmonary bypass times (182 ± 58 min vs. 114 ± 26 min, p < 0.0001) and aortic cross-clamp (151 ± 26 min vs. 98 ± 22 min, p < 0.0001) times were longer in combined procedures. As expected, EuroScore-2 was higher in patients who had undergone Bentall plus CABG in comparison with isolated operations (6.6% ± 1.5% vs. 4.7% ± 0.3%, p = 0.05). In addition, patients who had undergone Bentall plus CABG had an older age at the time of the surgery (72.1 ± 13 years vs. 64.4 ± 16 years, p = 0.001), a higher incidence of arterial hypertension (90% vs. 75%, p = 0.04), and calcific steno-insufficiency on the tricuspid aortic valve (79% vs. 47%, p = 0.05). The mean number of coronary bypass graft per patient was 2 ± 1. Left internal mammary artery was used as a graft for the anterior descending artery when the latter was involved in atherosclerotic disease, and in all cases, the aim was to obtain complete revascularization. Operative mortality was 1.38% (n = 3): 0.62% (n = 1/159) for isolated Bentall operation, and 3.44% (n = 2/58) for combined procedures. There was no mortality in patients who had undergone mechanical prostheses valved conduit implantation. A 85-year-old male patient died from postoperative perioperative respiratory failure and septic shock; another 80-year-old male patient died from low cardiac output syndrome and multiple organ failure; the other one 78-year female patient died for sudden death at 3 weeks from operation. Low cardiac output syndrome occurred in 20 patients (9.22%). In the logistic regression analysis, preoperative higher value of pulmonary arterial pressure (43 ± 14 vs. 33 ± 7 mmHg), longer times of cardiopulmonary bypass (167 ± 63 min vs. 126 ± 43 min), and aortic cross-clamp (132 ± 46 min vs. 108 ± 33 min) were detected as independent predictors of operative mortality and cardiac complications ( Table 1 ).

Independent predictors for hospital mortality and low cardiac output syndrome.

CPB: cardiopulmonary bypass; CABG: coronary artery bypass grafting.

The incidence of postoperative early surgical re-exploration for bleeding, stroke, and pacemaker implantation were 3.22% (n = 7/217), 0.46% (n = 1/217), and 4.15% (n = 9/217), respectively. In four patients (1.84%), it was necessary to perform a temporary percutaneous tracheostomy due to severe primary respiratory insufficiency. The median postoperative in-hospital stay was 9.5 days.

3.1. Survival and Freedom Curves from Adverse Events

During follow-up, there were 10 deaths out of 212 patients (4.7%); of them, two patients died for cardiac causes, i.e., endocarditis and congestive heart failure. At seven years, actuarial survival was 93% ± 2% ( Figure 1 ) and adverse-event-free survival was 81% ± 5% ( Figure 2 ). Freedom from death from cardiac causes was 99% ± 1%, from endocarditis–redo operation, 86% ± 5%, and from stroke, 99% ± 1%, respectively ( Figure 3 a–c).

Survival after Bentall operation (mean follow-up, 55 ± 24 (M 60.2) months).

Event-free survival after Bentall operation.

Freedom from late cardiac death ( a ); from endocarditis and redo operation ( b ); from stroke ( c ).

In the Cox regression analysis, concomitant CABG during the Bentall operation was the only independent predictor for reduced survival (HR = 1.9, p = 0.04) and event-free survival (HR = 2.3; p = 0.02). All the other variables mentioned in the statistical section of the methods, including age and the type of valve disease, i.e., steno-insufficiency or isolated insufficiency of the aortic valve, were not identified in the Cox analysis as risk factors for reduced survival and event-free survival. In the Mantel–Cox log-rank test, late survival was affected by CABG (84% ± 8% vs. 95% ± 2%, p = 0.04), preoperative myocardial infarction (91% ± 9% vs. 97% ± 2%, p = 0.02), and biological vs. mechanical prostheses valved conduits (91% ± 9% vs. 95% ± 3%, p = 0.02) ( Figure 4 a–c). Freedom from endocarditis–reoperation was 83% ± 9% for biological vs. 89% ± 6% for mechanical prostheses valved conduits ( p = not significant) ( Figure 5 ). Overall event-free survival also was affected by CABG (62% ± 14% vs. 85% ± 5%, p = 0.005) ( Figure 6 ) and, although with a statistical value that does not reach significance, by the use of biological prostheses (78% ± 8% vs. 84% ± 6%, p = 0.06) ( Figure 7 ).

Survival stratified by biological vs. mechanical prostheses ( a ); concomitant CABG ( b ); presence of previous MI ( c ) (log rank, Mantel–Cox test). CABG: coronary artery bypass grafting; MI: myocardial infarction.

Freedom from endocarditis–redo operation stratified by biological vs. mechanical prostheses valved conduits (Mantel–Cox test).

Adverse-event-free survival stratified by concomitant CABG (Mantel–Cox test). CABG: coronary artery bypass grafting.

Event-free survival stratified by biological vs. mechanical prostheses valved conduits (Mantel–Cox test).

3.2. Clinical Conditions during the Follow-Up Period

New York Heart Association functional class significantly improved in comparison with preoperative value (1.3 ± 0.5 vs. 2.0 ± 0.9; p < 0.0001). As compared with preoperative values, echocardiography data evaluation showed a significant improvement of cardiac parameters in terms of trans-aortic valve mean ( p < 0.0001) and maximum ( p < 0.0001) gradients, regression of the left ventricular hypertrophy ( p < 0.05), and reduction of pulmonary arterial pressure ( p = 0.002) ( Table 2 ).

Echocardiographic variables.

* Not including deaths and patients lost during follow-up.

4. Discussion

The principal findings of our study are that today, again, Bentall operation can be considered the gold standard for the treatment of different types of ascending aortic root aneurysms being associated with low rates of operative mortality and late complications; concomitant coronary ischemic disease and myocardial infarction affect late outcomes; and biological prostheses should be preferred for the elderly. In our experience, in-hospital mortality was 0.62% for the isolated Bentall operation and was absent in younger patients, thus being comparable to the operative risk predicted by the STS risk calculator and by the EuroScore-2 in patients undergoing coronary artery bypass grafting or isolated aortic valve replacement. Our findings appear to be in agreement with what is reported in large case studies in the literature [ 8 , 9 , 10 , 11 , 12 , 13 ]. Even in the combined operations, the operative mortality, although approximately three times higher, i.e., 3.44%, was nevertheless acceptable, also taking into consideration the preoperative EuroScore-2 value, which was greater than 6% in this subgroup of patients. Furthermore, it is reported that the greater the number of procedures per year, the lower the operative mortality. In our center, Bentall operation is the most practiced for the treatment of ascending aortic aneurysms, accounting for over 90% of aortic interventions, with an average of 30 Bentall operations per year in the observed period of surgical activity. For this reason, over the years we have extended the surgical indication to include expansive aneurysms of 50 mm in the absence of risk factors in order to prevent acute aortic complications [ 14 ]. On the contrary, in low-volume centers, mortality can exceed 5%, and the incidence of major cardiac complications, such as myocardial infarction with or without low cardiac output syndrome, and complete AV block, can reach a range between 11 and 15% [ 2 , 3 ]. Similarly, the incidence of stroke, renal failure, and postoperative bleeding is not negligible, especially during combined interventions, reaching values, respectively, greater than 3%, 6%, and 9% [ 2 , 3 , 15 ]. In our analysis on the perioperative outcome, independent risk factors for early mortality and major cardiac complications, i.e., low cardiac output syndrome, were a higher value of preoperative pulmonary arterial pressure, i.e., >40 mmHg, and longer times of cardiopulmonary bypass and aortic cross-clamp. In several reports, independent predictors of mortality reported are age greater than 70 years, preoperative NYHA III-IV, reoperation, concomitant mitral valve replacement, and CABG, or a greater preoperative comorbidity. The mean duration of cardiopulmonary bypass, i.e., 114 ± 26 min, and aortic clamping, i.e., 98 ± 22 min, observed in our series was found to be in line with what was reported in a large meta-analysis of 29 studies, performed in 3298 patients, i.e., 185 (range 112 to 318) minutes and 124 (range 76 to 242) minutes, respectively [ 15 ]. The low operative mortality, especially in the isolated Bentall operation and in patients who implanted mechanical conduits, i.e., 0.62% and absent, respectively, may have depended on various intraoperative technical factors that we adopted. Most of the operations (187 out of 217, 86%) were performed by the director surgeon (G.R.), very experienced in the treatment of aortic pathology, who implemented special technical measures. The most fearful complications after Bentall operation are related to the malposition of the perianastomotic suture of the coronary ostia, which can cause torsion, dissection, laceration, or late development of pseudoaneurysm. An incorrect ostia reimplantation can cause mortality due to myocardial infarction, low cardiac output syndrome, and right ventricular dysfunction. In fact, particular care was taken by us, which consists of the partial mobilization of both ostia, in order to avoid postoperative kinking. Moreover, especially in order to prevent the development of late periostial pseudoaneurysms, the correct orientation of the suture of the ostia, in particular of the right one, was assessed by using colored reference point for the correct initiation of the anastomosis on the slot of the tubular Dacron prosthesis.

To prevent periostial coronary buttons bleeding, particular care was performed during the anastomosis, gently favoring the juxtaposition between the coronary ostia and prosthetic tissue, and at the same time pulling the polypropylene thread of the anastomosis for correct hemostasis with a hook after the first three–four steps with 5-0 polypropylene suture. Early bleeding from the implantation of the right coronary ostium was found in one patient only (0.46%), who underwent surgical re-exploration on the fourth postoperative day. We used the same technique to perform the distal anastomosis between the prosthetic conduit and the aortic tissue with the 4-0 polypropylene, with the interposition of a Teflon strip along the entire perianastomotic suture. Such technical measures could justify the fact that during the follow-up, we did not observe the development of perianastomotic coronary button pseudoaneurysms or at the distal level of the anastomosis of the prosthesis. On the contrary, an exception was made for the development of proximal abscess pseudoaneurysms due to prosthetic endocarditis observed in 10 patients during follow-up. Yamabe et al. [ 16 ], on a series of 580 patients undergoing modified Bentall operation, reported that at 10 years there was a 6.1% reoperation rate for noninfectious causes. Of the 34 reoperated patients, cause of reoperation was, in 20.6% of cases, the formation of pseudoaneurysms or aneurysms of the aorta distal to the prosthetic conduit, and, in 2.9% of cases, the development of coronary button pseudoaneurysm.

Considering the average age at surgery, i.e., 66 years, the 7-year actuarial survival of 93% and event-free survival of 89% ( Figure 1 and Figure 2 ) were very satisfactory, and in line with what is reported in the literature. Di Marco et al. [ 11 ] reported a survival rate of 84.1% at 5 years and 65.5% at 10 years, respectively, on a population of 1045 patients with an average age at surgery of 59 years. Gaudino et al. [ 12 ], on 289 patients with a valved conduit with mechanical prostheses and 421 with biological prostheses, reported a survival of 91.7% and 81.5%, respectively, at 5 years; van Putte et al. [ 17 ], out of 528 patients with a mean age of 54 years, reported a 5-year survival rate of 87%. In the Cox regression analysis, the main independent predictor of reduced survival and freedom from adverse events was the concomitant presence of ischemic heart disease (HRs, 1.9–2.3). In fact, both the previous myocardial infarction and the need to perform concomitant CABG resulted in an overall reduction in freedom from adverse events of about 10–20% at 7 years (Mantel–Cox tests) ( Figure 3 b,c). Concomitant ischemic heart disease has also been recognized as a risk factor in other studies [ 11 , 12 , 13 , 17 ]. However, it should be emphasized that the freedom from cardiac death was very satisfactory, being 99% ( Figure 2 ). It could be hypothesized that it was not the presence of ischemic disease only, “per se”, that determined higher risk of death related to cardiac causes, but rather the fact that patients were also affected by higher EuroScore risk profile and greater comorbidity, such as advanced age and risk cardiovascular factors that can lead to a higher all-causes mortality.

A final aspect that we analyzed was the choice of the type of valved conduit, with mechanical or biological prostheses. Our policy adopted for Bentall operation follows that for isolated aortic valve replacement, with the exception of the cases provided for by the guidelines or the patient-related choice for the implantation of a biological prosthesis, we prefer to use the biological prostheses for patients of 70 years, and the mechanical prostheses in younger patients with no contraindications to long-term anticoagulation. This orientation is related to the fact that even in the most recent 2021 guidelines, a higher mortality was observed during long-term follow-up, i.e., at 10 and 15 years, in patients under the age of 60 years, and aged between 50 and 70 years, who have an implanted biological valve in the aortic position [ 18 ]. Furthermore, during follow-up we did not observe major bleeding events after mechanical prostheses implantation, and freedom from stroke was 99%. For these reasons, from our analysis, we do not believe that the extensive use of biological prostheses for younger patients is justified, as the operative risk of reoperation may exceed that associated with long-term anticoagulant therapy. Moreover, the reported risk of redo operation is higher than 7%, and if the etiology is endocarditic, it reaches over 20% [ 16 , 19 , 20 ]. One reason for the low incidence of thromboembolic and hemorrhagic valve mechanical-related events may be found in the particular care that physicians and younger patients take in taking anticoagulant therapy at the correct dosage, to maintain the INR range between two and three. Several studies in the literature compared the results of Bentall with biological and mechanical conduit, analyzing survival, the risk of reoperation, and endocarditis. Svensson and coworkers [ 13 ] reported that bioprosthesis Bentall patients had higher risk of late death at 15 years (57% vs. 14–26% for other aortic root replacement procedures, p < 0.0001). Werner et al. [ 21 ], in patients aged 50–70 years, found at 10 years a survival rate not different between mechanical (n = 151) and biological (n = 110) valved conduits, showing a higher risk in the mechanical group in the early postoperative phase, which declined during the follow-up ( p = 0.069). Pantaleo and coworkers [ 22 ], in a propensity score analysis of 138 mechanical and 138 biological Bentall operations, reported, at 5 years, similar survival (83.7% vs. 87.3%, p = 0.9), a substantially similar freedom from proximal aortic reintervention (99% vs. 93%) with a p value at the log-rank test of 0.07, and from endocarditis (99% vs. 83%, against biological prostheses, p = 0.2). Castrovinci et al. [ 15 ], in a meta-analysis of 14 studies on 1882 biological conduits implanted in patients aged 67 years old, reported at 5 years of follow-up a survival rate of 76%, freedom from reoperation at 90%, and freedom from endocarditis at 94%. In our analysis, freedom from endocarditis and reoperation at 6 years was substantially the same for the two types, mechanical (n = 113) and biological (n = 101) prostheses (93.6% vs. 93.2%, p = 0.5) ( Figure 5 ), while actuarial survival (95% vs. 91%, p = 0.01) and event-free survival (89% vs. 88%, p = 0.06) ( Figure 7 ) were better after mechanical prostheses implantation. A possible, or at least one, explanation of the reduced freedom from adverse events in patients with biological prostheses in the mid-term follow-up could be related to their older age at the intervention and to a greater comorbidity, i.e., related to the ischemic heart disease, although the statistical analysis did not detect the older age as a risk factor. Therefore, in the light of the comparative data observed during our follow-up and from other studies, and of the considerations we mentioned above, we would like to recommend the use of biological prostheses in older patients.

Despite being a fairly large study population, the more important limitations include its retrospective nature and a follow-up period up to the medium term.

In conclusion, low rates of operative mortality and late complications make Bentall operation the gold standard for the treatment of aortic root aneurysms. Coronary ischemic disease and myocardial infarction affect late outcomes. Biological prostheses should be preferred for the elderly.

Funding Statement

This research received no external funding.

Author Contributions

Made substantial contributions to conception and design of the study: P.N., C.B., C.P. and G.R. Made contributions to perform data analysis and interpretation: P.N. Data acquisition, provided administrative, technical and material support: F.B., A.C.S., D.B., D.T., L.A., M.S., C.A. and G.R. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and it was approved by the Independent Ethics Committee of Tor Vergata University Hospital (237.22).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

All the authors declare that they have no competing financial interests or personal relationships that could have influenced the work reported in this paper.

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Early outcomes of the Bentall procedure after previous cardiac surgery

• Amine Mazine, MD, MSc Amine Mazine Affiliations Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada Search for articles by this author
• Tirone E. David, MD Tirone E. David Affiliations Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada Search for articles by this author
• Myriam Lafreniere-Roula, PhD Myriam Lafreniere-Roula Affiliations Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada Search for articles by this author
• Christopher M. Feindel, MD Christopher M. Feindel Affiliations Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada Search for articles by this author
• Maral Ouzounian, MD, PhD Maral Ouzounian Correspondence Address for reprints: Maral Ouzounian, MD, PhD, Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth St 4N-464, Toronto, ON M5G 2C4, Canada . Contact Affiliations Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada Search for articles by this author

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• Preview In this month’s issue of the Journal of Thoracic and Cardiovascular Surgery , Mazine and colleagues 1 present an impressive review of their 24-year analysis from their noted cardiac center summarizing the results in 473 patients who underwent a Bentall procedure after a previous cardiac surgical procedure. Mazine and colleagues 1 conclude that “reoperative aortic root replacement with a Bentall procedure is associated with a significant operative risk, even in experienced hands. The need for complex coronary reimplantation techniques is an important factor associated with predictor of adverse perioperative events.” Not only are the clinical findings of their analysis are important in this challenging population of patients, also relevant is the opportunity to appreciate fully the applications of the myriad techniques in their series of Bentall procedures that have evolved in the surgical treatments of diseases of the anatomically complex structure known as the aortic root.
• Preview Aortic root replacement in the setting of previous cardiac surgery can be a formidable undertaking, as described by the authors from Toronto General. At times, identifying the annulus, or even something strong enough to hold annular stitches, can be difficult to recognize. The most intimidating cases can be those that had previous root manipulation, especially given the potential combination of coronary button immobility and tissue friability. Overall, Mazine and colleagues 1 demonstrate the important considerations required for the optimal care of these difficult patients.

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Bentall Procedure: Everything You Need to Know

A Surgery to Repair the Aortic Root and Aortic Valve

How to Prepare

• Day of Surgery

The Bentall procedure is a type of serious open-heart surgery needed to repair the aortic root and the aortic valve, such as might be needed for an aortic aneurysm in this part of the aorta . The procedure is named for Hugh Bentall, who first performed and described it in 1968.  

Westend61 / Getty Images

What Is the Bentall Procedure?

The Bentall procedure is a type of open-heart surgery to replace the aortic valve and aortic root (and sometimes more of the ascending aorta).   It might be formed as a pre-planned surgery or under emergency circumstances. To understand the Bentall procedure, it’s helpful to understand a little about the anatomy of the heart and blood vessels.

The aorta is the large blood vessel that carries oxygenated blood from the heart. Blood vessels leaving the aorta provide oxygenated blood to the whole body.

The aortic valve , which lies just where the aorta connects with the heart, prevents blood from flowing backward into the heart.

The aortic “root” is a term used for the very beginning of the aorta. You also might hear the term “ascending aorta,” which refers to a slightly longer portion of the aorta (before any blood vessels have branched off it), including the root itself.

Sometimes the aortic root can develop an aneurysm, the general term for a blood vessel that balloons out and becomes larger than normal in size. When that happens, it can affect how well the valve functions as well.

Contraindications

A person might not be able to have a Bentall procedure if they aren’t medically stable enough to have a major heart surgery (e.g., their blood pressure is too low).

Potential Risks

Like all forms of open-heart surgery, the Bentall procedure has inherent risks. It is a serious intervention, and unfortunately not everyone survives. One study cited the risk of death within 30 days of hospitalization at around 5%.

The risks of possible complications include the following:

• Abnormal heart rhythm
• Low cardiac output
• Heart attack
• Infection (e.g., sepsis , pneumonia, or surgical wound infection)
• Internal bleeding (which might necessitate surgical repair)
• Sudden kidney failure (which might be temporary or permanent)
• Prolonged need for mechanical ventilation
• New aortic aneurysm or dissection of the aorta

You may have a greater risk of certain of these complications if you have other medical conditions (like diabetes) or if your existing heart condition is particularly severe. Fortunately, the risks of some of these complications have decreased since the procedure was first performed, due to improved surgical techniques.

Purpose of the Bentall Procedure

The problems with the aorta and aortic valve can happen due to a variety of medical problems.

One of the most common is Marfan syndrome , a genetic condition that causes problems with a person’s connective tissue, including some of the tissue in the aortic root and valve. This can cause the area not to form normally or to develop problems over time. In addition to other potential medical problems, a person with Marfan syndrome might have an aneurysm form in their ascending aorta.  

However, sometimes people develop problems in these areas for other reasons. Other possible underlying causes include:

• Other hereditary syndromes that affect the heart
• Physical trauma
• Infection (like from a bacterial infection)
• Autoimmune disease (like from Takayasu arteritis )
• Congenital heart problems
• General degeneration (caused by high blood pressure, atherosclerosis, and smoking)  

In any case, these problems need to be surgically repaired if the aneurysm is large enough. The most important consideration is the risk that the aneurysm will start to dissect . That means that the layers of the blood vessel will start to separate.

This can cause the artery to burst, leading to a life-threatening emergency. To prevent this, some intervention, such as the Bentall procedure, is necessary. The Bentall procedure might also be needed as an emergency surgery if an aneurysm has already ruptured.

To evaluate whether a Bentall (or similar) procedure is needed, you’ll need some medical imaging. Depending on the context, this might mean one or more of the following:

• Chest X-ray
• Transthoracic echocardiography
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI): Cardiac MRI and/or MRI angiography

Through these imaging techniques, your healthcare providers can check out your specific anatomy and evaluate whether the Bentall procedure is the best way for you to go.

Choosing Surgical or Medical Management

Not everyone with an aortic root aneurysm will need surgical repair (such as a Bentall procedure). It’s important to weigh the risks of surgery with the risks of not having the surgery.

If the aneurysm is small, it’s unlikely to dissect. If that’s the case, your healthcare provider might recommend waiting on surgery and monitoring you with imaging techniques, at least initially.

For people who don’t have an underlying medical condition that caused their problem (other than high blood pressure), it’s currently recommended to have preventative surgery when the aorta diameter is 5.5 centimeters (cm) or if it seems to be growing quickly.

However, your healthcare provider might recommend the surgery even if your aorta isn’t quite that big if you have a condition like Marfan syndrome.

If you decide not to have surgery (at least for the present), your healthcare provider may recommend treatment with medications instead, especially those to lower your blood pressure. For example, you might need to start taking a beta blocker (like propranolol) or an ACE-inhibitor (like captopril).

Other people may need to take a statin drug (like Lipitor) if they have atherosclerosis that may have contributed to their condition. However, none of these medications fixes the underlying problem.

Clearance for Surgery

Before your surgery is planned, your healthcare provider will want to make sure you are in good condition for it. This will include a general medical history and medical exam. It may also include some tests like EKG, basic blood work like a complete blood count (CBC) , and others as needed.

If you experience serious symptoms, like sudden chest pain or shortness of breath, call 911 right away. This may be a sign that your aneurysm has started to dissect. Seek immediate medical attention for this potentially life-threatening emergency.

Picking Your Surgery Type

Depending on the exact situation, you might have surgical options other than a Bentall procedure. Sometimes, healthcare providers may be able to repair the aortic root without needing to replace the aortic valve through a newer surgical technique. This is sometimes called a “valve sparing” procedure.

In this case, the procedure performed is not technically a Bentall procedure. This procedure may have a reduced risk of complications compared to a Bentall, such as the risk of endocarditis .

Another advantage over some types of Bentall procedures is that a valve sparing surgery does not require long-term treatment with anticoagulant medications. Some healthcare providers now recommend such a procedure over a Bentall in situations in which it is medically possible. But it’s not always a viable option.

Bentall Procedure Valve Selection

When planning to have a Bentall procedure, one of the key choices to make is whether to have a mechanical valve replacement or a valve replacement performed with a synthetic, biologic material.

The advantage of choosing a mechanical valve is that they are very durable and last for many years. However, people who have mechanical valves need to be on life-long anticoagulation treatment (such as via warfarin ).

This helps ensure that you don’t get a blood clot that forms on the replacement valve. However, these medications come with risks (particularly increased risk of bleeding) and a greater need for monitoring for the rest of your life.

On the other hand, if you have a synthetic biological valve replacement, you won’t need to take anticoagulation medications. A disadvantage is that these valves don’t last as long as mechanical valves, so you may be more likely to need a follow-up surgery.

Working with your healthcare provider, you can make the best surgical choice for you based on your clinical situation, your age, and your lifestyle preferences.

The procedure will be performed in the surgical or cardiac wing of your chosen hospital.

What to Wear

It doesn’t matter what you wear when you come to the hospital. You may want to leave any valuables, such as rings, at home.

Before you go to surgery, you’ll need to change into a hospital gown. You’ll need to remove any jewelry, glasses or contacts, hearing aids, or dentures.

Food and Drink

Like other surgeries, you’ll need to not eat or drink ahead of time, in order to reduce the risk of complications. Typically, you’ll be asked not to eat or drink anything after midnight the night before your planned surgery.

Medications

Before the surgery, make sure your healthcare provider knows about all the medications you are taking, including over-the-counter ones. Particularly make sure to ask about medications that might affect blood clotting, such as aspirin or anticoagulant medications like warfarin.

Your healthcare provider might want you to stop taking them for a time before the surgery, but don’t do this without checking in first. It’s also a good idea to bring a printed list of your medications on the day of your surgery itself.

What to Bring

Because you will need to be in the hospital for several days, bring whatever you need to help you feel comfortable (e.g., slippers, a robe). It’s also a good idea to bring your insurance information.

Pre-Op Lifestyle Changes

If you are a smoker, it’s a good idea to quit before your surgery. Even quitting the day before can help you reduce your risk of complications, but longer is better.  

What to Expect on the Day of Surgery

Before the procedure.

You’ll be expected to arrive well ahead of your surgery. You’ll be evaluated by one or more health professionals who will make sure that you are in good health to move forward with the procedure.  

For example, you’ll be asked about any new symptoms, like fever. You’ll also probably be asked again about other parts of your medical history, like your allergies and your current medications. If anything is unusual with your health, this is the chance to share that information.

Someone will also check your vital signs, like your blood pressure, and you’ll have a basic medical exam performed. Someone may also shave the area around your chest.

During the Surgery

The operation should take around five hours, but it might be more. (This doesn’t include the preparatory period or the time in surgical recovery). A whole surgical team will be available to monitor your vital signs and help get you through the surgery successfully.

Eventually you’ll be taken from a preoperative area into the surgical room itself. You’ll receive general anesthesia during the operation, so you won’t feel any pain, and you won’t remember anything about it afterward.

Someone will insert a catheter to collect your urine during the operation. You'll also have a special tube placed down your airway, which will be connected to a ventilator.

When everything is ready, the surgeon will make a cut in your chest, through the breastbone, to access the aortic valve and the aorta.

During the part of the surgery on the heart and related structures, you will be connected to a heart-lung bypass machine . This machine can do the work that your heart and lungs would normally do. This allows the surgeon to stop your heart temporarily while working on the aorta and its valve.

The surgeon will clamp the aorta and remove the damaged section of the aorta and valve. Then the surgeon will replace that part of the aorta with a prosthetic tube (called a graft). Inside the graft is an artificial aortic valve (either of the mechanical type or one made of biological tissue).

The surgeon will surgically connect one end of the graft to your remaining, normal aorta. The other end containing the valve is also sewn into the heart. The surgeon will also need to sew the coronary arteries (that bring blood to the heart itself), to make sure they receive adequate blood flow after the operation.

After everything is in place, the clamp can be removed. You’ll come off the heart-lung machine and your heartbeat will be restarted, as the blood flows through the artificial valve and graft and out into the rest of your body.

Depending on the exact clinical situation, the Bentall procedure may not be the only procedure necessary for your heart. For example, you might need repair or replacement of a different heart valve, or you might need some other sort of heart intervention. If so, these can take place either right before or right after the Bentall procedure.

Your sternum may be closed with wires. The surgeon will also surgically close the incision across your chest. 

The exact details of the procedure will vary based on the specific version of the Bentall technique your surgeon is choosing. Don’t feel like you have to get overly involved in the details, but don’t hesitate to bring up any questions that you have.

After the Surgery

Someone will take you to a surgical recovery area, where you’ll be carefully monitored. After a while, you’ll wake up, but you may be groggy for a while.

At first, you may be attached to a ventilator via an endotracheal tube . You’ll have one or more tubes attached to drain excess fluid and air from your chest. You might also have a catheter in the artery in your wrist (an arterial line) so your medical team can better monitor your condition.  

If everything seems to be going well, you’ll be moved to the room where you’ll stay overnight, probably in the intensive care unit. Here they can carefully monitor you and make sure you aren’t having any immediate complications from your surgery, such as blood clot in your leg or lungs.

If you need to, you can have medication for the pain following the surgery. Usually, people can eat and drink again the day following surgery. After a day or so in the intensive care unit, you will probably be able to move to a general medical floor.

You’ll need to stay in the hospital for several days until you are well enough to go home. During this time, people will regularly be checking on your incision to make sure it is healing properly.

They’ll also be checking to see that you are able to pass stool without straining (as extra pressure might put stress on your wound). The urine catheter and chest tube are able to be removed within a couple of days.  

As soon as you can manage it, you’ll want to try moving around again. This will reduce your chance of complications, like forming a blood clot.

Before you leave, you’ll receive instructions on follow-up care, such as continued care for your healing chest incision . You may still need to keep it away from water until your wound fully heals.

You’ll also receive instructions on when you will see your healthcare provider again (such as a week or so later in an outpatient clinic). Someone will need to be able to drive you home. You won’t be able to do that yourself for a few weeks or so, or maybe more.

Call 911 right away for signs of potentially serious complications like sudden chest pain. Call your healthcare provider promptly if you have other new symptoms, like fever. These might indicate a complication that needs medical attention.

Coping With Recovery

Even when you are ready to leave the hospital, you may still fatigue easily. You need to give yourself time to recover from this major surgery.

Some people will benefit from cardiac rehabilitation to help get them moving again. Your healthcare provider is the best person to tell you when you are ready to return to your normal activities, but it may take you a several months to fully recover.

Long-Term Care

If you had a problem with your aorta and valve due to another condition, do what you can to decrease your risk of a future aneurysm . For example, if you have atherosclerosis and/or high blood pressure, taking your medications as prescribed may help you reduce your risk.

Quitting smoking may also help you decrease your risk of a future aneurysm and of certain complications.  

Additionally, people who receive a mechanical valve as part of their Bentall procedure will need to receive life-long anticoagulation . As part of this, you may need to receive regular blood tests to make sure your blood is clotting the right amount.  

Possible Future Surgeries

Some people who receive the Bentall procedure do very well and never need repeat surgery. However, some people eventually need to have another surgery.

This might be more likely to happen if you have a disease like Marfan syndrome, and the underlying problem causes another aneurysm to develop. In this case, you might need some kind of surgical repair on your aorta.  

A Word From Verywell

There’s a lot to consider if you have a problem with your aorta and aortic valve that might benefit from the Bentall procedure. Surgery might or might not be the best option for you, depending on your situation.

Beyond that, you may have choices about your surgical options, including whether to have a Bentall procedure specifically and whether you want to receive a mechanical valve. Discuss all the pros and cons with your healthcare provider to help make the best choice for you.

Kouchoukos NT, Haynes M, Baker JN. The button Bentall procedure . Oper Tech Thorac Cardiovasc Surg . 2018;23(2):50-61. doi:10.1053/j.optechstcvs.2018.12.002

Joo HC, Chang BC, Youn YN, Yoo KJ, Lee S. Clinical experience with the Bentall procedure: 28 years . Yonsei Med J . 2012;53(5):915-923. doi:10.3349/ymj.2012.53.5.915

Mookhoek A, Korteland NM, Arabkhani B, et al. Bentall procedure: a systematic review and meta-analysis . Ann Thorac Surg . 2016 May;101(5):1684-9. doi:10.1016/j.athoracsur.2015.10.090

Pepe G, Giusti B, Sticchi E, Abbate R, Gensini GF, Nistri S. Marfan syndrome: current perspectives .  Appl Clin Genet . 2016;9:55-65. doi:10.2147/TACG.S96233

Saliba E, Sia Y; In collaboration with. The ascending aortic aneurysm: When to intervene? .  Int J Cardiol Heart Vasc . 2015;6:91-100. doi:10.1016/j.ijcha.2015.01.009

Lavall D, Schäfers HJ, Böhm M, Laufs U. Aneurysms of the ascending aorta .  Dtsch Arztebl Int . 2012;109(13):227-233. doi:10.3238/arztebl.2012.0227

National Heart, Lung, and Blood Institute. Heart surgery . 

De Paulis R, Scaffa R, Salica A, Weltert L, Chirichilli I. Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit .  J Vis Surg . 2018;4:94. doi:10.21037/jovs.2018.04.12

Applegate PM, Boyd WD, Applegate RL, Liu H. Is it the time to reconsider the choice of valves for cardiac surgery: mechanical or bioprosthetic? .  J Biomed Res . 2017;31(5):373-376. doi:10.7555/JBR.31.20170027

American Society of Anesthesiologists. Smoking . 

Johns Hopkins Medicine. Heart and Vascular Institute. Cardiac surgery: A guide for patients and their families . 2011. 

By Ruth Jessen Hickman, MD Dr. Hickman is a freelance medical and health writer specializing in physician news and patient education.

• Open access
• Published: 19 December 2022

Early and midterm outcomes of a bentall operation using an all-biological valved BioConduit™

• Roxana Botea 1 , 2 ,
• Yoan Lavie-Badie 2 ,
• Alexandru Goicea 1 , 3 ,
• Jean Porterie 1 &
• Bertrand Marcheix 1  

Journal of Cardiothoracic Surgery volume  17 , Article number:  325 ( 2022 ) Cite this article

1358 Accesses

Metrics details

To analyze the midterm results of aortic root replacement using the valved, all biological, No React®, BioConduit™.

From 2017 to 2020, we prospectively followed 91 consecutive patients who underwent a Bentall procedure with a BioConduit™ valved graft in our institution. The primary outcomes were aortic bioprosthetic valve dysfunction and mortality according to Valve Academic Research Consortium 3 (VARC3).

Mean age was 70 ± 10 years and 67 patients (74%) were men. Ascending aortic aneurysm (72%), aortic valve regurgitation (51%) or stenosis (20%) and acute endocarditis (14%) were the main indications for surgery. Seventy-four patients (81.3%) were followed up at 1 year. The perioperative mortality was 8% (n = 8), the early, 1 year, mortality was 2% (n = 2) and the midterm mortality, at 4 years of follow up, was 4% (n = 3). Ten patients fulfilled the criteria for hemodynamic valve deterioration at 1 year (13%) and 14 for a bioprosthetic valve failure during the entire follow-up (17%).

Conclusions

We are reporting early and midterm results of Bentall procedures with the all-biological, valved, No-React® BioConduit™. To our knowledge, this is the first study reporting an early and midterm unexpectedly high rate of non-structural prosthetic hemodynamic deterioration. The rate of endocarditis and atrioventricular disconnections remain similar to previous studies.

Peer Review reports

The Bentall procedure is the gold standard therapy in patients with either ascending aorta or aortic root aneurysm combined with aortic valve disease precluding a valve sparing procedure. [ 1 ]. The original technique described by Bentall and De Bono using a composite mechanical valved graft benefited from iterative refinements in order to overcome specific surgical drawbacks [ 2 ]. Nowadays, either preassembled or self-assembled conduits, associating tubular straight or Valsalva graft and biological or mechanical valve, are widely used [ 3 , 4 ]. As an alternative, a fully xenobiological stentless valved conduit, the Shelhigh NR-2000, was introduced in the late 1990’s and thereafter withdrawn from the market. Recently, a totally biological stentless conduits have been reintroduced in a modified version, using a porcine aortic valve and a bovine pericardial tube (BioIntegral™, BioValsalva™). The goal of our study was to investigate the early and midterm results of the Bentall procedure using BioIntegral™ BioConduit™ in our single-center experience.

Study design

It was a prospective observational study, without control-group, carried out from 2017 to 2020 in our tertiary centre.

Study population

All consecutive patients undergoing a Bentall procedure with the BioIntegral™ Surgical BioConduit™ No-React® in our institution (n = 91) were prospectively included during the study period. All patient data were collected from hospitals’ medical records. Cohort patients underwent an aortic root replacement with an all-biological graft in cases of complex endocarditis or redo surgeries, cases of patients who were not candidates for an autograft procedure but a mechanical graft was not indicated and in elderly patients with degenerative aortic root disease.

The study is conformed to the principles outlined in the Declaration of Helsinki. According to French law on ethics, patients were informed that their codified data would be used for the study. The patient also provided informed written consent for the publication of the study data. The Institutional Review Board of the Rangueil University Hospital of Toulouse, France, approved the study protocol and the publication of data (number RnlPH 2022-50) on the 7th of April 2022.

Surgical data

All interventions were performed by four senior surgeons. All patients were operated through median sternotomy. Standard cardiopulmonary bypass, aortic cross-clamp and anterograde and retrograde cold blood potassium-enriched cardioplegia were used in all patients. When an aortic arch replacement was performed, moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion through the right axillary artery were associated. After aortic cross-clamping, the aortic valve, the aortic root and the ascending aorta were excised, followed by aortic annulus decalcification when required. The coronary ostia were isolated with their buttons. After sizing of the aortic annulus, the prosthesis was chosen, with a trend in oversizing. The all-biological stentless valved bioconduit is designed to offer similar hemodynamics as the native aortic valve and theoretically aimed to insure a larger post-operative effective orifice area (EOA). The conduits’ No-React® treatment aims to reduce the grafts’ related infections and calcifications as well as to prevent remodeling and graft aneurysmal dilatation [ 5 , 6 , 7 ]. As the traditional glutaraldehyde preserved biological valves tend to calcify, the No-React® detoxification process promises to eliminate residual glutaraldehyde and to ensure stable tissue cross-linking, resulting in less or no calcification or tissue deterioration in the animal model [ 5 , 6 ]. A variety of BioConduit™ sizes between 21 to 29 mm were implanted. The trend of oversizing refers to choosing a conduit one-size oversized following the manufacturer’s recommendations, to achieve greater effective surface areas, avoiding mismatch [ 7 ]. Depending on operator preferences, two types of implantation techniques were used, either multiple single, interrupted, non-everting, reinforced U-stiches to implant the composite graft in supra-annular position (n = 33, 36%) or everting stitches to implant the prosthesis in intra-annular position (n = 58, 64%). Then, 2 holes were made in the tubular graft and both coronary ostia were reimplanted by running sutures (Prolene 6–0). Fibrin glue was used in most cases to reinforce sutures.

Imaging protocol

A post-operative transthoracic echocardiographic (TTE) assessment was performed before hospital discharge: 2D TTE standard views were obtained using a standard ultrasound system using a 1–5 MHz probe (VIVID S70, GE Healthcare). A new TTE assessment was conducted at 1 year, using the same system. EOA was calculated by the continuity equation method. Aortic annulus diameter was measured at mid-systole, from the parasternal long-axis view, at the level of the prosthetic annulus, in a zoomed mode, from inner-edge to inner-edge. The velocity–time integral of blood flow was measured in the left ventricular outflow track by pulsed doppler. Mean transaortic gradient and maximal velocity were evaluated by transprosthetic continuous wave doppler. The doppler velocity index was calculated as the ratio of the proximal peak flow velocity in the LVOT to the transprothetic peak flow velocity. All examinations were interpreted blindly on a dedicated workstation (EchoPac 204 GE Healthcare) by two operators. In addition, during the follow-up, in case of bioprosthetic valve failure (BVF), a TEE and a cardiac CT were performed.

Study outcomes

The endpoints used were those proposed by the Valve Academic Research Consortium 3 (VARC3).

Mortality [ 8 ]

Periprocedural mortality was defined as all-cause mortality occurring ≤ 30 days after the index procedure or occurring > 30 days but during the index hospitalization.

Early mortality was defined as death occurring > 30 days but ≤ 1 year after the index hospitalization.

Midterm mortality was defined as death occurring > 1 year after the index hospitalization but ≤ 4 years, at end of follow up.

Aortic bioprosthetic valve dysfunction (BVD)

In terms of etiology, BVDs were defined as structural valve deterioration (SVD), nonstructural valve dysfunction (NSVD), thrombosis or endocarditis. SVD was reported as intrinsic permanent changes of the prosthetic valve [ 9 ]. NSVD was reported as any abnormality not intrinsic to the bioprosthesis, resulting in its malfunction (e.g. pannus, prosthesis-patient mismatch) [ 9 ].

Hemodynamic valve performance assessment was protocolized at 1 year of the index procedure. Moderate hemodynamic valvular deterioration (HVD) was defined as an increase in the transaortic mean gradient of \(\ge\) 10 mmHg resulting in a mean gradient of \(\ge\) 20 mmHg, with concomitant decrease in the EOA \(\ge\) 0.3 cm 2 and decrease in doppler velocity index \(\ge\) 0.1 compared to the post-operative assessment. Severe HVD was defined as an increase in the mean gradient of \(\ge\) 20 mmHg resulting in a mean gradient of \(\ge\) 30 mmHg, with concomitant decrease in the EOA \(\ge\) 0.6 cm 2 and decrease in doppler velocity index \(\ge\) 0.2 [ 9 ].

During the follow-up, the occurrence of a BVF was considered as an endpoint. Finally, BVF was defined by the occurrence of BVD associated with clinically expressive criteria (heart failure symptoms, fever, angina, ischemic event), irreversible severe HVD, aortic valve reoperation or re-intervention or valve-related death [ 9 ].

Statistical analysis

Continuous variables were expressed as means ± standard deviation or as medians with interquartile ranges (IQR) when not normally distributed. Nominal variables were expressed as numbers and percentages. The association between the mean values of continuous variables was assessed using the Mann–Whitney rank sum test. Nominal variables were investigated by the χ 2 test or the Fisher exact test when appropriate. The software XLSTATS v2019.1 (Addinsoft, Paris, FR) was used for statistical analysis.

This study included 91 patients, mostly men (74%) with a mean age at intervention of 70 ± 10 years. Preoperative patient’s characteristics are reported in Table 1 . Most patients had an ascending aortic aneurysm (n = 65, 72%). There were 22 cases of redo procedures (24%). Sixteen procedures were performed on an emergency basis (18%), including 10 cases of type A acute aortic dissection (11%), 12 cases of severe prosthetic endocarditis (13%) and 1 complex of native aorto-mitral endocarditis. Forty-four patients underwent combined interventions (48%): coronary artery bypass graft in 22 cases (24%), mitral valve repair or replacement in 5 (6%) and aortic arch or hemiarch replacement in 14 (15.3%) cases.

Among the 83 patients discharged from hospital, 9 were lost to follow-up (10%). Median follow-up was 4 years.

The periprocedural mortality rate was 8% (n = 8). Among them, 3 patients with a pre-operative severe left ventricular dysfunction died shortly after the procedure from low cardiac output and multiorgan failure syndrome, 2 patients operated for complicated infective endocarditis on previous Bentall prosthesis died in the first 24 h from refractory septic vasoplegic syndrome, 2 patients operated for acute type A aortic dissection died either from massive hemorrhagic stroke or acute right ventricular failure in the first week after surgery and 1 patient experienced acute respiratory distress syndrome.

Early mortality rate was 2%. Among the 83 patients discharged from hospital, 2 died in the first year, both of them experiencing graft proximal anastomosis partial detachment at 9 and 10 months, respectively. Both were reoperated, but died from hemorrhagic stroke or massive intraoperative bleeding, respectively.

Midterm mortality rate was 4% (3 patients). One 62 years-old male, who had already undergone two Bentall procedures presented a recurrent bacterial graft endocarditis at 18 months after discharge. He was referred to surgery and died in the operating room from uncontrolled bleeding. One 83 years-old patient died from respiratory distress related to a severe form of Covid-19 pneumonia. The third, 72 years-old male died from metastatic pulmonary adenocarcinoma.

Bioprosthetic valve dysfunction

Early results

Regarding the prosthetic hemodynamic features, despite normal postoperative hemodynamic profiles, without signs of obstruction, we observed a decrease in graft performance at 1 year, mainly in terms of EOA (1.3 ± 0.2 cm 2 vs 0.9 ± 0.4 cm 2 , p = 0.02 for 23 mm graft, 1.6 ± 0.4 cm 2 vs 1.2 ± 0.5 cm 2 , p = 0.01 for 25 mm graft, 1.9 ± 0.5 cm 2 vs 1.5 ± 0.5 cm 2 , p < 0.01 for 27 mm graft, 2.1 ± 0.6 cm 2 vs 1.6 ± 0.6 cm 2 , p = 0.17 for 29 mm graft) but also in terms of transaortic mean gradient and maximum velocity. [ 10 , 11 ].

At the 1-year follow-up, 10 patients fulfilled criteria for HVD (13%), 6 being moderate and 4 severe. The factors associated with HVD are presented in Table 2 . Preoperative characteristics were not associated with HVD. The implanted graft caliber was significantly associated with the occurrence of HVD at 1 year (8 (80%) vs. 21 (33%), p  = 0.01 for 23- or 25-mm graft), especially in the smallest sizes.

However, the patients who secondarily developed HVD had similar hemodynamic parameters as the rest of the cohort at the pre-discharge postoperative exam.

There was 1 case (1.3%) of early graft endocarditis with negative blood cultures, diagnosed at 8 months after surgery. We treated it medically.

We noted three cases (4.1%) of partial proximal anastomosis disruption: two cases with total atrio-ventricular disruption with large false aneurysms at the level of the proximal anastomosis at 9 months and respectively at 10 months after the initial surgery. We did not find any argument in favor of an infective endocarditis. Moreover, one patient’s initial surgery was in an elective setting, for a degenerative aortic aneurysm. The third patient had a similar aortic root disruption, but it appeared 4 months after a Bentall intervention for a complex aortic and mitral endocarditis with fragile tissues.

Midterm results

Five patients experienced infective endocarditis (6.8%) at a median of 1 year and 4 months. One patient was treated surgically and the other 5, medically.

There weren’t observed any more cases of hemodynamic dysfunction or AV disruptions until follow up was closed.

Regarding early and midterm results, we observed a total of 14 patients presenting a BVF during follow-up (17%). A re-intervention was performed in 8 cases (10%). Three patients had a valve-in-valve TAVR for severe HVD. Five patients had open redo surgery: three cases of partial proximal anastomosis detachment, one case of graft endocarditis with valvular involvement and one severe HVD. Among them, 3 patients died related to the procedure.

Regarding etiologies of BVF, 6 patients experienced infective endocarditis (8%), 3 patients had partial proximal anastomosis detachment (4%) and the other 4 patients had severe irreversible HVD (5.5%). All patients with endocarditis underwent TTE and TEE which were abnormal in two cases, highlighting valve involvement (aortic vegetations (n = 2), aortomitral abscess (n = 1) and pseudoaneurysm (n = 1)). Endocarditis patients also underwent a CT scan which showed in all cases a proximal collection around the biological graft with peripheral contrast diffusion, without signs of a pseudoaneurysm. PET combined with CT (PET/CT) was also performed in four cases, showing an abnormal intense uptake on the graft collection and/or the valvular prosthesis. Regarding the pathogens involved, there were 2 cases of staphylococcus involvement (aureus and epidermidis), 1 with Enterobacter Aerogenes, 1 with E. coli, another case a streptococcus oralis infection and lastly, 1 with negative blood cultures.

For all patients with HVD, thrombosis was ruled out by CT, and endocarditis by Duke criteria. SVD was eliminated by TEE and CT. Of note, none of these patients had regurgitation. Regarding NSVD, a patients-prosthesis mismatch did not appear to be involved, as postoperative indexed EOA was not associated with the occurrence of HVD at 1 year. Finally, for all patients with HVD, imaging found a 3–4 mm, circumferential, hyperechogenic ring, located at the level of the prosthetic aortic annulus and at the graft’s proximal anastomosis towards its’ ventricular side, near the pledgets. In these patients, on CT and TEE, there was no structural prosthetic abnormality (neither fibrosis, calcification, leaflet tear and wear, hypo-attenuated leaflet thickening nor thrombosis). Moreover, we have randomly reviewed patients’ echocardiographic exams concluding that the circumferential structure is a common finding in patients being implanted with this type of biological graft. Indeed, 29 patients had a reduction of their aortic annulus size at 1 year (39%). We identified this annular structure in the per-operatory setting, during the reintervention for a failing bioprosthesis (Fig.  1 ).

A Transesophageal echocardiography, deep transgastric view, annular hyperechogenic structure (yellow arrow); LVOT—left ventricle outflow tract; B Intraoperative view with the annular diaphragmatic structure (black arrow) visualized after complete prosthetic dissection

This prospective study reports the midterm outcomes of 91 consecutive patients who underwent a Bentall procedure with the BioConduit™ No React® between 2017 and 2020, in our institution. Main results are as follows: 1) the hemodynamic performances at 1 year were unsatisfying, with an overall trend towards reduction in EOA and a significant rate of HVD, 2) despite the No-react® treatment of the conduit, graft endocarditis was not rare and 3) we observed some cases of early graft detachment at its proximal anastomosis with the aortic root.

Biological bioconduits, by avoiding stent and sewing cuff at the annular level, are intended to achieve more physiological flow pattern and thus superior hemodynamics [ 7 , 12 , 13 ]. However, our study identified a high rate of HVD and a general decrease in EOA at 1 year as being related to prosthesis of smaller calibers (23 and 25 mm) ( p  < 0.001) and renal insufficiency ( p  < 0.001) (Table 2 ). Even though we observed a general reduction in the annulus diameter, we think it had a more rapid obstructive impact in initially smaller calibers.

Regarding patients with HVD, our imaging protocol allowed us to rule out endocarditis, thrombosis or SVD in all cases. Our main observation explaining this phenomenon causing NSVD might be similar to a pannus formation. Firstly, we noticed a reduction in the aortic annulus diameter at 1 year (Fig.  2 ). In addition, we found a 3–4 mm, external circumferential, hyperechogenic, non-perfused ring, situated at the level of the prosthetic aortic annulus and at the graft’s proximal anastomosis near the pledgets. This structure was identified during our imaging protocol and confirmed in the perioperative setting (Fig.  1 ). We concluded that HVD was probably related to the external circumferential diaphragm that explained the shrinkage of the aortic diameter. Nevertheless, it is interesting to notice the rapid development of this “pannus-like” structure, in less than a year (Additional files 1 , 2 , 3 ). Concerning its potential cause, several hypotheses are put forward. It may be related to the surgical techniques as the structure was near the pledgets used for our surgical interrupted suture, reinforced with biological fibrin glue.

Transthoracic echocardiography, long axis parasternal view with same patient early post-operatory ( A ) and ( C ) and 1-year follow up exam ( B ) and ( D ), showing a shrinkage of the aortic annulus at 1 year (measured at the level of the yellow arrows), from 18 to 14 mm ( A ) and ( C ) together with a transaortic mean gradient and maximal velocity by Doppler continuous wave interrogation, from 2,4 m/sec and 12 mmHg ( B ) to 4,6 m/sec and 59 mmHg ( D )

As for the surgical implantation technique, we used either a multiple, single, interrupted, non-everting, pledged reinforced U-stiches to implant the composite graft in supra-annular position (n = 33, 36%) or everting stitches to implant the prosthesis in intra-annular position (n = 58, 64%). After univariate analysis, we found no correlation between the technique and the event of bioprosthetic valve dysfunction (Table 2 , p  = 0.47).

We can also consider the role of the immune system. The glutaraldehyde bioconduit treatment is meant to eliminate immunogenic proteins [ 14 ]. Nevertheless, multiple observational studies identified xenograft porcine components (extracellular matrix specific glycans, galactose-a-1,3-galactose and N-glycolylneuraminic acid) who trigger host antibody formation [ 15 , 16 , 17 , 18 , 19 ]. Sustaining the same immunogenic hypothesis, a group from Munich studied the effects of a pericardial porcine, No-React® patch and they found sterile abscess formation that was suspected to be an immunogenic reaction, a xenogeneic complement-mediated graft rejection [ 20 ]. The question of patient-prosthesis mismatch can be raised because the smallest sizes of prostheses seemed to be more sensitive to hemodynamic deterioration. We believe that this observation is not related to an initial mismatch but to the fact that a decrease in EOA logically has more impact on a small prosthesis than on a larger one.

In light of all of the above, we speculate an early inflammatory reaction could have been triggered by the biological conduit itself, favored by the use of biological glue or/and by the surgical technique (all patients were implanted using a multiple, single, interrupted, everting or non-everting suture with pledged reinforced U-stiches). Lastly, concerning the surgical technique, we note that other teams (Carrel et al., Stefanelli et al., Sahin et al., Kaya et al., Galinanes et al.) reported using as technique of conduit implantation either a running suture or an interrupted, nevertheless, they were not confronted with this problem [ 13 , 21 , 22 , 23 , 24 ].

Six patients were diagnosed with graft endocarditis. Diagnosis was made according to the modified Duke criteria and was often difficult, due to a combination of atypical clinical, biological, radiological and echocardiographic observations [ 25 ]. These features are not specific to this conduit and are usual after Bentall surgery. These results are surprising insofar as one of the advantages put forward in favor of these conduits is their expected low rate of reinfection.

In this regard, Galinanes et al. reported excellent late results (1 case of conduit infective endocarditis in 10 years) [ 13 ]. Siniawski et al., Musci et al. and Wendt et al. suggested the same reassuring results [ 26 , 27 , 31 ]. Recently, Stefanelli et al. also reported satisfactory results, with freedom from the BioConduit® graft infection of 95.7% at 5 and 15 years (CI 0.95) [ 22 ]. However, larger cohorts are still needed to confirm these results.

Previous studies reported a high number of aorto-ventricular disconnections especially related to the initial Shelhigh’s biological conduit [ 21 , 23 , 24 , 28 ]. The Shelhigh graft was a stentless, valved, No-React® biological conduit implanted mostly in the early 2000s. Due to unexpected conduit disconnections, in 2007, the United States FDA published a notification, the product being retried of the market [ 28 , 30 ]. Despite this drawback, in 2013, Musci et al. published reassuring results after 11 years of follow-up of 255 patients implanted with Shelhigh initial graft [ 30 ]. The Berlin group reported a low reinfection rate (0.78% early and 2.35% late reinfection) concluding that patients’ outcome was dependent of their surgical urgency. Afterwards, a new version of the graft, the BioIntegral Surgical, BioConduit™ was released on the market. Regarding its predecessor (the Shelhigh conduit), while some teams report relatively satisfactory early and late follow-up results (Galinanes et al., Musci et al.), other teams report some dreadful complications (Sahin et al., Kaya et al., Carrel et al., Reineke et al., Sadeque et al.) referring to the high rate of endocarditis and of atrio-ventricular disconnections with proximal false aneurysm formation [ 13 , 21 , 23 , 24 , 27 , 28 , 29 , 30 , 32 ]. In contrast, they report conduit hemodynamic dysfunction only in a few cases. Reineke et al. describes 8 cases (2.3%) with structural valve deterioration at late follow up. In contrast, Kaya et al. reports 3 cases (1.7%) with hemodynamic failure at early follow-up, without detailing. Concerning the BioConduit™, Stefanelli et at publishes satisfactory early and long-term results [ 22 ]. In our series, we report 10 cases (13%) presenting criteria for non-structural hemodynamic valve dysfunction at 1 year and 4 of them fulfilling criteria for failure, needing reintervention. This was an unexpected finding, as to our knowledge, such a high incidence of biological conduit hemodynamic dysfunction was never cited before.

There are several limitations of this study. This was a prospective but single-center, non-randomized study with lack of group control. Even though there were 91 patients included, the population analyzed was rather small and heterogenous, gathering elective as well as emergent cases. Being a single institution study, with 4 surgeons and 2 techniques, while representing a limitation, could contribute to reducing biases related to the use of multiple techniques.

This study reports the early and midterm results of the newest all-biological valved conduit. Even though it is designed to achieve superior hemodynamics by excluding the valvular stent, our study reveals an abnormally high rate of early prosthetic non-structural dysfunction and failure that appears to be mostly related to a multifactorial progressive shrinkage of the aortic annulus. Regarding graft infections, we observed that endocarditis is not rare, despite conduits all-biological structure. Lastly, there are still some cases of conduit proximal anastomotic detachments.

Availability of data and materials

The datasets and the materials used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Bioprosthetic valve failure

Effective orifice area

Hemodynamic valve deterioration

Nonstructural valve deterioration

Patient-prosthesis mismatch

Structural valve deterioration

Transcatheter aortic valve replacement

Transesophageal echocardiogram

Transthoracic echocardiogram

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The corresponding author (RB) and YL-B conceived and designed the analysis. AG collected data and conceived the tables. YL-B performed the statistical analysis. All authors discussed the results and contributed to the final manuscript. The corresponding author and JP wrote the paper. All authors read and approved the final manuscript.

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Additional file 1. Video 1 Transthoracic echocardiography, long axis parasternal view. Exam at 1-year follow up exam showing a diminished and hyperechogenic, with a pannus-like structure at the level of the aortic annulus.

Additional file 2.  Video 2 Transthoracic echocardiography, long axis parasternal view. Exam at 1-year follow up exam showing a diminished and hyperechogenic, with a pannus-like structure at the level of the aortic annulus.

Additional file 3. Video 3 Transthoracic echocardiography, long axis parasternal view. Exam at 1-year follow up exam showing a diminished and hyperechogenic, with a pannus-like structure at the level of the aortic annulus.

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Botea, R., Lavie-Badie, Y., Goicea, A. et al. Early and midterm outcomes of a bentall operation using an all-biological valved BioConduit™. J Cardiothorac Surg 17 , 325 (2022). https://doi.org/10.1186/s13019-022-02073-5

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Bentall procedure as a lifesaving surgery: A single center experience

• Saif S. Al-Mudhaffar
• Abdullah Mowaffaq
• Fahmi H. Kakamad
• Okba F. Ahmad
• Dana H. Mohammed-Saeed
• Razhan K. Ali
• Berun A. Abdalla
• Shvan H. Mohammed
• Abdulwahid M. Salih

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• Corresponding author: Author name
• Published online on: January 10, 2023     https://doi.org/10.3892/mi.2023.68
• Article Number: 8

Copyright: © Al-Mudhaffar et al . This is an open access article distributed under the terms of Creative Commons Attribution License.

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Introduction.

The Bentall procedure is a surgical technique used in the management of aortic root abnormalities with ascending aorta and aortic valve dysfunctions. It was first described by Bentall and De Bono ( 1 ) in 1968 and subsequently also described by others ( 2 ). The technique was typically invented to treat patients with aortic root aneurysms. It was then modified in several aspects. Bentall procedures mainly involve the insertion of a mechanical valve conduit to replace the aortic root. It is regarded as a long-term solution, while it requires long-life anticoagulation ( 3 , 4 ). Aortic root dilatation with or without aortic valve dysfunction may cause spontaneous dissection and rupture of the aorta. The patient is placed in a critical situation with the need for rapid lifesaving intervention. The application of the Bentall procedure with its various techniques provides a positive impact on the result; overall life expectancy has also markedly increased over the past 30 years ( 5 ). All the previous repairing modalities, such as plication, supracoronary aortic replacement and aneurysm banding were insufficient to complete the removal of the diseased aortic tissue. These methods resulted in increased post-operative complications and mortality rates ( 6 ). In recent years, the Bentall procedure has become the gold standard modality in the management of aortic root replacement. It is one of the most curative surgical procedures in the field of cardiac surgery ( 7-9 ). The present study aimed to evaluate the outcomes of the Bentall procedure conducted in a single center among a total of 18 patients.

Patients and methods

Study design.

The present study was a single-center retrospective case series. A total of 18 patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction were included in the study. Patients were enrolled at the Ibn Al-Bitar Specialized Center for Cardiac Surgery (Baghdad, Iraq) from December, 2017 to January, 2020. Ethical approval was provided by the Iraqi Board of Medical Specialization with the approval no. 00245/2017. Written consent was taken from all included patients to participate in the study.

Patient preparation and analyses

The patients were all initially examined by a general practitioner and then referred to a cardiologist. The cardiologist examined the patients and performed examinations for vital signs, as well as an echocardiography. The results of the echocardiography revealed a bicuspid aortic valve in 14 cases (77.7%). Pericardial effusion ranged from mild to tamponade in 12 patients (66%) and all of the patients had aortic root dissection with severe aortic incompetence. Due to the need for a coronary artery bypass graft, all the cases were discussed in a multidisciplinary team (MDT) meeting with the involvement of cardiac surgeons. The outcome of the MDT meeting was to refer the cases to the cardiac surgeons for proper management. The cardiac surgeons re-examined the patients' results, and any investigation which had been conducted >6 weeks prior was conducted again.

Inclusion criteria

The present study included all the patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction that had undergone the Bentall procedure at the center between December, 2017 to January, 2020.

Data collection and analysis

An electronic registry database was used to register the patients' medical records, including demographics, medical summary, investigations, surgical indications, procedure specifications, comorbidities and follow-up information. The data were encoded and descriptively analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.

Surgical technique

The procedures were performed via standard median sternotomy. A cardiopulmonary bypass was conducted by cannulating the ascending aorta and combined with the femoral artery or axillary artery in a direct method, and venous return via right atrium venous cannulation. Axillary cannulation was performed for all cases of aortic dissection and sometimes for certain cases of aneurysms involving the aortic arch. Otherwise, regular ascending aortic cannulation was used. Myocardial protection was provided by simultaneous antegrade and retrograde perfusion using del Nido blood cardioplegic solution, either with crystalloid or mixed with blood (Nephron Pharmaceutical Corporation).

Deep hypothermic circulatory arrest (20 c) was used in all cases that had an aortic dissection. Longitudinal aortotomy was performed just above the sino tubular junction to inspect the ascending aorta, aortic root, aortic valve, intimal tear and the site of dissection. Both the coronary ostia were mobilized and excised with the aortic wall patch to facilitate the re-implantation of the composite graft, aortic cusp resection, the resection of the diseased part of the ascending aorta, and the inspection of the aortic arch condition and aortic valve sizing.

The St. Jude Medical composite graft with Valsalva (St. Jude Medical, Inc.) was applied in all the cases. Polyester sutures (2/0) with pledgets in an interrupted manner were used for the implantation of the composite on the aortic root. The coronary ostia anastomosis was performed using a 6\0 proline suture in a continuous manner. Distal anastomosis of the graft to the aortic arch was performed following fixation of the dissection extension with a 4/0 proline suture with a pledget in an interrupted manner. The graft anastomosis with a 4/0 proline suture was conducted in a continuous manner to the aortic arch. Biological glue was used to secure the anastomosis sites and decrease the risk of bleeding.

The age of the participants ranged from 27-60 years, with a mean age of 40 years. The ratio of males to females was 16:2 (males, 88.8%) ( Table I ). Chest pain was the most common presenting symptom (n=10, 55.5%); of the 10 patients with chest pain, 9 patients had an aortic dissection, and 1 patient had aortic root dilatation and coronary artery disease. The symptoms developed 3-4 days prior to hospital admission. Hypertension was the most common risk factor (n=12, 66.6%). In total, 14 cases (77.7%) had bicuspid aortic valve. Elevated renal indices were noted in 8 patients (44.4%), with which cardiogenic shock was the cause of six of these. Concomitant heart disease was found in 3 patients (16.6%). A total of 14 cases underwent emergency surgery (77.7%). The emergency surgery was performed in 9 patients within 24 h of arrival owing to the association of aortic root dissection with tamponade. For the other cases, the surgery was performed within 2 and 7 days (n=5, 27.7% and n=4, 22.2%) respectively. The aneurysmal size and extension of aortic dissection were the main indications for axillary cannulation (16 patients, 88.9%) and the femoral site was used for cannulation in 2 patients (11.1%) ( Table II ).

Baseline characteristics of the patients.

Data of surgery and outcomes.

Early post-operative complications occurred in 5 patients (27.7%). Surgical bleeding and re-exploration occurred in 1 patient (5.55%). Stroke (n=1, 5.55%), atrial fibrillation (n=2, 11.1%) and acute kidney injury (n=1, 5.55%) were also recorded ( Table II ). The patient with acute kidney injury was managed according to the KIDIGO protocol ( 10 ) with continuous renal replacement therapy (CCRT). This was the only patient that passed away during the study. All the variables including, the patients' age, gender, risk factors, etiology, operation data and post-operative data are all summarized in Tables I and II .

It is almost six decades since Bentall and De Bono ( 1 ) described a novel surgical technique for the management of aortic root aneurysm. After a number of years, the technique, with several additional alternations, had become the gold standard approach in managing abnormalities of the aortic valve, ascending aorta and the aortic root. For that reason, investigations of the outcomes of the new approaches to the Bentall procedures have been widely suggested ( 7 ). The present case series is a single center experience that includes the patients who had an abnormality of ascending dissection and/or dilated ascending aorta. The results were compared to those of previous related studies.

In a case series conducted by Spittell et al ( 11 ), the majority of the patients had been affected by the aortic dissection during their 60-70 years of life. Males were predominant over females at a 2:1 ratio. Systemic hypertension is regarded as the most common risk factor for aortic dissection. Congenitally malformed aortic valve also plays a significant role in the presentation of aortic dissection. In the study by Spittell et al ( 11 ), a bicuspid aortic valve was reported in 17 patients. One of the rare causes of congestive heart failure related to aortic dissection is the rupturing of the dissection and extending into the atria or right ventricle. Therefore, patients with acute congestive heart failure that have a history of chest pain should be examined for aortic dissection ( 11 ).

Some studies have mentioned the congenital bicuspid valves as a distinctive risk of early aneurysm formation. In the study by Hagl et al ( 7 ) bicuspid aortic valve was associated with aneurysm formation in almost 50% of the cases. Several other factors, such as arteriosclerosis, diabetes and Marfan syndrome have been reported to be combined with the aneurysm and dissection of the aorta ( 7 , 12 ). The present study differed from the study of Spittell et al ( 11 ) regarding the age of the patients. Hypertension was the most common risk factor (66.6%) as stated in the previous study. A bicuspid aortic valve was found in 77.7% of the cases. Approximately 78% of the patients had an aortic dissection in that study, but none of the cases were associated with a dissection rupture extending into the atria and the right ventricle.

The instant onset of chest pain is the typical symptom of aortic dissection. It has been reported to present in >94% of patients ( 13 ). Some other studies have described lower extremity ischemia as the frequent manifestation of aortic dissection ( 11 , 14-16 ). Chest pain is a universal symptom that can be easily confused with other common illnesses. Aortic root dissection is an uncommon disorder and ranges from 2.6 to 3.5 per 100,000 individuals/year ( 17 , 18 ). These findings can cause patient referral delays and the condition of patients may deteriorate before arrival. Other studies have reported that the mortality rate increases 1-2% for every hour without any treatment ( 19 ). Caution should be practiced regarding the pattern of chest pain in a patient with acute aortic dissection. All the cases in our experience had been referred late (2-3 days following the onset of symptoms). Chest pain was the most presenting symptom (55.5%) and 90% of patients had aortic root dissection. This is comparable with the finding of other studies ( 11 , 20 ). The present study reported acute kidney injury in 1 patient (5.5%) who was managed with CRRT. In addition, Etz et al ( 4 ) reported renal issues required dialysis in 8 patients (2.2%).

There is a low mortality rate associated with the Bentall procedure. The early mortality rate in the study by Gelsomino et al ( 21 ) was only 5.5% and Benke et al ( 22 ) reported a mortality rate of 3.4%. Yakut ( 23 ) performed aortic root replacement in 80 patients using a flanged composite graft. He reported a mortality rate of 8.75%; the major point to be mentioned is that none of the cases succumbed due to flange-related complications ( 23 ). Some independent risk factors have been reported to be associated with mortality after the Bentall procedure, including hypertension, diabetes mellitus, elderly, severe ventricular dysfunction, Marfan syndrome, dissection, endocarditis, previous cardiac surgery, coronary artery disease and left ventricle ejection fraction ( 24 ). Despite the association of several mentioned risk factors with some of the cases in the present study, the mortality rate due to these risks was insignificant. In the present case series, the early mortality rate was (5.5%) due to acute kidney injury complications. The present study reported this percentage of mortality as all the cases were operated on as emergency cases. From the beginning of the practice in the present study, the aortic dissection team was established to take rapid action for emergency intervention. This helped to decrease the preparation time and the mortality rate.

Using composite grafts to replace the ascending aorta may be a low-risk and successful operation when the platelet preservation technique is applied. Previous studies have used coronary artery bypass surgery with aprotinin to decrease the rate of blood losses during both the intra-operative and post-operative period ( 25 , 26 ). In the present study, axillary arterial cannulation was used for all cases with aortic dissection for easy initiation of antegrade cerebral perfusion during circulatory arrest and to reduce the rate of cerebral embolization compared with femoral cannulation. To decrease myocardial oxygen demand and work in a bloodless field to improve myocardial protection during surgery, del Nido blood cardioplegic solution was perfused in an antegrade and retrograde, and the venting of the right upper pulmonary vein and hypothermic circulatory arrest (20c) were used.

In the present case series, post-operative bleeding occurred in 1 patient (5.5%) and this required re-exploration. A stroke occurred in 1 patient (5.5%) and was managed medically. However, Zehr et al ( 27 ) reported that 8 cases (4%) developed bleeding that required re-exploration. In addition, Etz et al ( 4 ) reported reopening surgery in 18.3% of the cases due to bleeding. In the present study, cardiac arrest occurred during anesthesia induction for all the cases with tamponade. They were managed with rapid exploration by opening the lower part of the sternum to evacuate the collected blood in the pericardium to relieve the heart compression. No re-exploration due to failure of the Bentall procedure was performed in the present study. Bio glues as fibrin sealant material were used to secure all sutures to decrease the risk of post-operative bleeding; this was also reported in the study by Della Corte et al ( 28 ).

There have been concerns regarding the risks of hemorrhage owing to the traction on the aortic wall in the classic Bentall procedure ( 22 ). Hagl et al ( 7 ) reported no technical failures in their study and they proposed the Bentall procedure, as a safe and durable technique with a low rate of post-operative complications. Some of the patients in the study by Hagl et al ( 7 ) required ensuing operations for aneurysms located in different sites of the aorta.

A diligent post-operative follow-up is strongly recommended for patients with disease of the ascending aorta ( 7 ). In the present case series, the results were satisfactory following the Bentall procedure. The results of the present study were in accordance with those of the study by Yakut ( 23 ). None of the patients succumbed due to the Bentall procedure.

The major limitations of the present study include the small, single-group sample size, the lack of proper data and statistical analysis (quantitative) and variables, the short-term duration of the study, and short or missing post-operative follow-up data.

In conclusion, in accordance with previous studies ( 21-23 ), the authors' experience confirmed that the Bentall procedure is a life-saving surgery and it may even be associated with no incident of mortality. Herein, 18 patients with aortic root dissection and dilatation were treated with this procedure. Raising the awareness of clinicians and the general population as regards aortic dissection may aid in the early referral of patients to specialized centers and may thus decrease the overall mortality rate.

Acknowledgements

Not applicable.

Funding: No funding was received.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' contributions

AA, SSAM, RO, AM, FHK and OFA were the cardiothoracic surgeons who managed the cases, performed the follow-up of the patients and obtained patient data. FHK, RKA and AMS were involved in the conception of the study, in performing the literature review, and also in the writing of the manuscript. DHMS, BAA, SHM and AM performed the literature review, qualitative data analysis, and examining patient data. All authors have read and approved the final manuscript. OFA and AA confirm the authenticity of all the raw data.

Ethics approval and consent to participate

The present study was approved by the Iraqi Board of Medical Specialization. Written informed consent was obtained from all the patients.

Patient consent for publication

Competing interests.

The authors declare that they have no competing interests.

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Bentall procedure as a lifesaving surgery: A single center experience.

Author information, affiliations.

• Al-Mudhaffar SS 1
• Mowaffaq A 1
• Kakamad FH 2, 5, 6
• Mohammed-Saeed DH 2, 5
• Salih AM 2, 5
• Abdalla BA 5, 6

ORCIDs linked to this article

• Ali RK | 0000-0002-0322-1648
• Alwan A | 0000-0002-1343-7637

Medicine International , 10 Jan 2023 , 3(1): 8 https://doi.org/10.3892/mi.2023.68   PMID: 36733412  PMCID: PMC9887084

Abstract 

Free full text , bentall procedure as a lifesaving surgery: a single center experience, saif s. al-mudhaffar.

1 Department of Cardiac Surgery, Ibn Al-Bitar Specialized Center for Cardiac Surgery, Baghdad 10011, Iraq

Abdullah Mowaffaq

Fahmi h. kakamad.

2 College of Medicine, University of Sulaimani, Sulaimani, Kurdistan 46000, Iraq

3 Smart Research Center, Smart Health Tower, Sulaimani, Kurdistan 46000, Iraq

4 Kscien Organization, Sulaimani, Kurdistan 46000, Iraq

Okba F. Ahmad

5 Department of Surgery, Mosul Cardiac Center, Mosul 41001, Iraq

Dana H. Mohammed-Saeed

6 Sulaimani Center for Heart Disease, Sulaimani, Kurdistan 46000, Iraq

Razhan K. Ali

7 Department of Surgery, Shar Hospital, Sulaimani, Kurdistan 46000, Iraq

Berun A. Abdalla

Shvan h. mohammed, abdulwahid m. salih, associated data.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

The Bentall procedure is a surgical technique used in the management of aortic root abnormalities with ascending aorta and aortic valve issues. The present study aimed to evaluate the outcomes of 18 patients treated with the Bentall procedure in a single center. The present study was a single-center retrospective case series conducted over a period of 3 years. The patients had either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction. The Bentall procedure was performed via standard median sternotomy. St. Jude Medical composite grafts with a valve were applied in all cases. A total number of 18 patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction were included in the study. The age of the participants ranged from 27-60 years. The ratio of males to females was 16:2 (males, 88.8%). The symptoms developed 3-4 days prior to hospital admission. Chest pain was the most common presenting symptom (n=10, 55.5%). Hypertension was the most common risk factor (n=12, 66.6%). In total, 14 cases underwent emergency surgery (77.7%). The emergency surgery was performed in 9 patients within 24 h of arrival owing to the association of aortic root dissection with tamponade. For the other cases, the surgery was performed within 2 and 7 days (n=5, 27.7% and n=4, 22.2%) respectively. Early post-operative complications occurred in 5 patients (27.7%). On the whole, as demonstrated herein, the modifications of the Bentall procedure have a notable impact on decreasing the overall mortality rates. Raising the awareness of clinicians and the general population as regards aortic dissection may aid in the early referral of patients to specialized centers and may thus decrease the overall mortality rate.

Introduction

The Bentall procedure is a surgical technique used in the management of aortic root abnormalities with ascending aorta and aortic valve dysfunctions. It was first described by Bentall and De Bono ( 1 ) in 1968 and subsequently also described by others ( 2 ). The technique was typically invented to treat patients with aortic root aneurysms. It was then modified in several aspects. Bentall procedures mainly involve the insertion of a mechanical valve conduit to replace the aortic root. It is regarded as a long-term solution, while it requires long-life anticoagulation ( 3 , 4 ). Aortic root dilatation with or without aortic valve dysfunction may cause spontaneous dissection and rupture of the aorta. The patient is placed in a critical situation with the need for rapid lifesaving intervention. The application of the Bentall procedure with its various techniques provides a positive impact on the result; overall life expectancy has also markedly increased over the past 30 years ( 5 ). All the previous repairing modalities, such as plication, supracoronary aortic replacement and aneurysm banding were insufficient to complete the removal of the diseased aortic tissue. These methods resulted in increased post-operative complications and mortality rates ( 6 ). In recent years, the Bentall procedure has become the gold standard modality in the management of aortic root replacement. It is one of the most curative surgical procedures in the field of cardiac surgery ( 7-9 ). The present study aimed to evaluate the outcomes of the Bentall procedure conducted in a single center among a total of 18 patients.

Patients and methods

Study design.

The present study was a single-center retrospective case series. A total of 18 patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction were included in the study. Patients were enrolled at the Ibn Al-Bitar Specialized Center for Cardiac Surgery (Baghdad, Iraq) from December, 2017 to January, 2020. Ethical approval was provided by the Iraqi Board of Medical Specialization with the approval no. 00245/2017. Written consent was taken from all included patients to participate in the study.

Patient preparation and analyses

The patients were all initially examined by a general practitioner and then referred to a cardiologist. The cardiologist examined the patients and performed examinations for vital signs, as well as an echocardiography. The results of the echocardiography revealed a bicuspid aortic valve in 14 cases (77.7%). Pericardial effusion ranged from mild to tamponade in 12 patients (66%) and all of the patients had aortic root dissection with severe aortic incompetence. Due to the need for a coronary artery bypass graft, all the cases were discussed in a multidisciplinary team (MDT) meeting with the involvement of cardiac surgeons. The outcome of the MDT meeting was to refer the cases to the cardiac surgeons for proper management. The cardiac surgeons re-examined the patients' results, and any investigation which had been conducted >6 weeks prior was conducted again.

Inclusion criteria

The present study included all the patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction that had undergone the Bentall procedure at the center between December, 2017 to January, 2020.

Data collection and analysis

An electronic registry database was used to register the patients' medical records, including demographics, medical summary, investigations, surgical indications, procedure specifications, comorbidities and follow-up information. The data were encoded and descriptively analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.

Surgical technique

The procedures were performed via standard median sternotomy. A cardiopulmonary bypass was conducted by cannulating the ascending aorta and combined with the femoral artery or axillary artery in a direct method, and venous return via right atrium venous cannulation. Axillary cannulation was performed for all cases of aortic dissection and sometimes for certain cases of aneurysms involving the aortic arch. Otherwise, regular ascending aortic cannulation was used. Myocardial protection was provided by simultaneous antegrade and retrograde perfusion using del Nido blood cardioplegic solution, either with crystalloid or mixed with blood (Nephron Pharmaceutical Corporation).

Deep hypothermic circulatory arrest (20 c) was used in all cases that had an aortic dissection. Longitudinal aortotomy was performed just above the sino tubular junction to inspect the ascending aorta, aortic root, aortic valve, intimal tear and the site of dissection. Both the coronary ostia were mobilized and excised with the aortic wall patch to facilitate the re-implantation of the composite graft, aortic cusp resection, the resection of the diseased part of the ascending aorta, and the inspection of the aortic arch condition and aortic valve sizing.

The St. Jude Medical composite graft with Valsalva (St. Jude Medical, Inc.) was applied in all the cases. Polyester sutures (2/0) with pledgets in an interrupted manner were used for the implantation of the composite on the aortic root. The coronary ostia anastomosis was performed using a 6\0 proline suture in a continuous manner. Distal anastomosis of the graft to the aortic arch was performed following fixation of the dissection extension with a 4/0 proline suture with a pledget in an interrupted manner. The graft anastomosis with a 4/0 proline suture was conducted in a continuous manner to the aortic arch. Biological glue was used to secure the anastomosis sites and decrease the risk of bleeding.

The age of the participants ranged from 27-60 years, with a mean age of 40 years. The ratio of males to females was 16:2 (males, 88.8%) ( Table I ). Chest pain was the most common presenting symptom (n=10, 55.5%); of the 10 patients with chest pain, 9 patients had an aortic dissection, and 1 patient had aortic root dilatation and coronary artery disease. The symptoms developed 3-4 days prior to hospital admission. Hypertension was the most common risk factor (n=12, 66.6%). In total, 14 cases (77.7%) had bicuspid aortic valve. Elevated renal indices were noted in 8 patients (44.4%), with which cardiogenic shock was the cause of six of these. Concomitant heart disease was found in 3 patients (16.6%). A total of 14 cases underwent emergency surgery (77.7%). The emergency surgery was performed in 9 patients within 24 h of arrival owing to the association of aortic root dissection with tamponade. For the other cases, the surgery was performed within 2 and 7 days (n=5, 27.7% and n=4, 22.2%) respectively. The aneurysmal size and extension of aortic dissection were the main indications for axillary cannulation (16 patients, 88.9%) and the femoral site was used for cannulation in 2 patients (11.1%) ( Table II ).

Baseline characteristics of the patients.

Data of surgery and outcomes.

Early post-operative complications occurred in 5 patients (27.7%). Surgical bleeding and re-exploration occurred in 1 patient (5.55%). Stroke (n=1, 5.55%), atrial fibrillation (n=2, 11.1%) and acute kidney injury (n=1, 5.55%) were also recorded ( Table II ). The patient with acute kidney injury was managed according to the KIDIGO protocol ( 10 ) with continuous renal replacement therapy (CCRT). This was the only patient that passed away during the study. All the variables including, the patients' age, gender, risk factors, etiology, operation data and post-operative data are all summarized in Tables I and ​ andII II .

It is almost six decades since Bentall and De Bono ( 1 ) described a novel surgical technique for the management of aortic root aneurysm. After a number of years, the technique, with several additional alternations, had become the gold standard approach in managing abnormalities of the aortic valve, ascending aorta and the aortic root. For that reason, investigations of the outcomes of the new approaches to the Bentall procedures have been widely suggested ( 7 ). The present case series is a single center experience that includes the patients who had an abnormality of ascending dissection and/or dilated ascending aorta. The results were compared to those of previous related studies.

In a case series conducted by Spittell et al ( 11 ), the majority of the patients had been affected by the aortic dissection during their 60-70 years of life. Males were predominant over females at a 2:1 ratio. Systemic hypertension is regarded as the most common risk factor for aortic dissection. Congenitally malformed aortic valve also plays a significant role in the presentation of aortic dissection. In the study by Spittell et al ( 11 ), a bicuspid aortic valve was reported in 17 patients. One of the rare causes of congestive heart failure related to aortic dissection is the rupturing of the dissection and extending into the atria or right ventricle. Therefore, patients with acute congestive heart failure that have a history of chest pain should be examined for aortic dissection ( 11 ).

Some studies have mentioned the congenital bicuspid valves as a distinctive risk of early aneurysm formation. In the study by Hagl et al ( 7 ) bicuspid aortic valve was associated with aneurysm formation in almost 50% of the cases. Several other factors, such as arteriosclerosis, diabetes and Marfan syndrome have been reported to be combined with the aneurysm and dissection of the aorta ( 7 , 12 ). The present study differed from the study of Spittell et al ( 11 ) regarding the age of the patients. Hypertension was the most common risk factor (66.6%) as stated in the previous study. A bicuspid aortic valve was found in 77.7% of the cases. Approximately 78% of the patients had an aortic dissection in that study, but none of the cases were associated with a dissection rupture extending into the atria and the right ventricle.

The instant onset of chest pain is the typical symptom of aortic dissection. It has been reported to present in >94% of patients ( 13 ). Some other studies have described lower extremity ischemia as the frequent manifestation of aortic dissection ( 11 , 14-16 ). Chest pain is a universal symptom that can be easily confused with other common illnesses. Aortic root dissection is an uncommon disorder and ranges from 2.6 to 3.5 per 100,000 individuals/year ( 17 , 18 ). These findings can cause patient referral delays and the condition of patients may deteriorate before arrival. Other studies have reported that the mortality rate increases 1-2% for every hour without any treatment ( 19 ). Caution should be practiced regarding the pattern of chest pain in a patient with acute aortic dissection. All the cases in our experience had been referred late (2-3 days following the onset of symptoms). Chest pain was the most presenting symptom (55.5%) and 90% of patients had aortic root dissection. This is comparable with the finding of other studies ( 11 , 20 ). The present study reported acute kidney injury in 1 patient (5.5%) who was managed with CRRT. In addition, Etz et al ( 4 ) reported renal issues required dialysis in 8 patients (2.2%).

There is a low mortality rate associated with the Bentall procedure. The early mortality rate in the study by Gelsomino et al ( 21 ) was only 5.5% and Benke et al ( 22 ) reported a mortality rate of 3.4%. Yakut ( 23 ) performed aortic root replacement in 80 patients using a flanged composite graft. He reported a mortality rate of 8.75%; the major point to be mentioned is that none of the cases succumbed due to flange-related complications ( 23 ). Some independent risk factors have been reported to be associated with mortality after the Bentall procedure, including hypertension, diabetes mellitus, elderly, severe ventricular dysfunction, Marfan syndrome, dissection, endocarditis, previous cardiac surgery, coronary artery disease and left ventricle ejection fraction ( 24 ). Despite the association of several mentioned risk factors with some of the cases in the present study, the mortality rate due to these risks was insignificant. In the present case series, the early mortality rate was (5.5%) due to acute kidney injury complications. The present study reported this percentage of mortality as all the cases were operated on as emergency cases. From the beginning of the practice in the present study, the aortic dissection team was established to take rapid action for emergency intervention. This helped to decrease the preparation time and the mortality rate.

Using composite grafts to replace the ascending aorta may be a low-risk and successful operation when the platelet preservation technique is applied. Previous studies have used coronary artery bypass surgery with aprotinin to decrease the rate of blood losses during both the intra-operative and post-operative period ( 25 , 26 ). In the present study, axillary arterial cannulation was used for all cases with aortic dissection for easy initiation of antegrade cerebral perfusion during circulatory arrest and to reduce the rate of cerebral embolization compared with femoral cannulation. To decrease myocardial oxygen demand and work in a bloodless field to improve myocardial protection during surgery, del Nido blood cardioplegic solution was perfused in an antegrade and retrograde, and the venting of the right upper pulmonary vein and hypothermic circulatory arrest (20c) were used.

In the present case series, post-operative bleeding occurred in 1 patient (5.5%) and this required re-exploration. A stroke occurred in 1 patient (5.5%) and was managed medically. However, Zehr et al ( 27 ) reported that 8 cases (4%) developed bleeding that required re-exploration. In addition, Etz et al ( 4 ) reported reopening surgery in 18.3% of the cases due to bleeding. In the present study, cardiac arrest occurred during anesthesia induction for all the cases with tamponade. They were managed with rapid exploration by opening the lower part of the sternum to evacuate the collected blood in the pericardium to relieve the heart compression. No re-exploration due to failure of the Bentall procedure was performed in the present study. Bio glues as fibrin sealant material were used to secure all sutures to decrease the risk of post-operative bleeding; this was also reported in the study by Della Corte et al ( 28 ).

There have been concerns regarding the risks of hemorrhage owing to the traction on the aortic wall in the classic Bentall procedure ( 22 ). Hagl et al ( 7 ) reported no technical failures in their study and they proposed the Bentall procedure, as a safe and durable technique with a low rate of post-operative complications. Some of the patients in the study by Hagl et al ( 7 ) required ensuing operations for aneurysms located in different sites of the aorta.

A diligent post-operative follow-up is strongly recommended for patients with disease of the ascending aorta ( 7 ). In the present case series, the results were satisfactory following the Bentall procedure. The results of the present study were in accordance with those of the study by Yakut ( 23 ). None of the patients succumbed due to the Bentall procedure.

The major limitations of the present study include the small, single-group sample size, the lack of proper data and statistical analysis (quantitative) and variables, the short-term duration of the study, and short or missing post-operative follow-up data.

In conclusion, in accordance with previous studies ( 21-23 ), the authors' experience confirmed that the Bentall procedure is a life-saving surgery and it may even be associated with no incident of mortality. Herein, 18 patients with aortic root dissection and dilatation were treated with this procedure. Raising the awareness of clinicians and the general population as regards aortic dissection may aid in the early referral of patients to specialized centers and may thus decrease the overall mortality rate.

Acknowledgements

Not applicable.

Funding Statement

Funding: No funding was received.

Availability of data and materials

Authors' contributions.

AA, SSAM, RO, AM, FHK and OFA were the cardiothoracic surgeons who managed the cases, performed the follow-up of the patients and obtained patient data. FHK, RKA and AMS were involved in the conception of the study, in performing the literature review, and also in the writing of the manuscript. DHMS, BAA, SHM and AM performed the literature review, qualitative data analysis, and examining patient data. All authors have read and approved the final manuscript. OFA and AA confirm the authenticity of all the raw data.

Ethics approval and consent to participate

The present study was approved by the Iraqi Board of Medical Specialization. Written informed consent was obtained from all the patients.

Patient consent for publication

Competing interests.

The authors declare that they have no competing interests.

Full text links 

Read article at publisher's site: https://doi.org/10.3892/mi.2023.68

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• PMID: 28330738
• DOI: 10.1016/j.diagmicrobio.2017.03.002

Introduction: The Bentall procedure is a cardiac surgery involving graft replacement of the aortic valve, aortic root and ascending aorta. Graft infection after Bentall's procedure (BGI) is infrequent but severe, and often difficult to diagnose and treat.

Patients and methods: A retrospective cohort study was performed using the Bordeaux endocarditis database of adult patients admitted to the Bordeaux University Medical Hospital for BGI between 2008 and 2014. Published case reports were identified in the literature.

Results: We identified 10 BGI patients in the database and 13 in the literature. The majority of infections were late-onset (20/23) and occurred as a result of gram positive cocci bacterial infection (16/22). Detailed diagnoses of the described BGI were determined using echocardiography, computed tomography (CT) and positron emission tomography/CT (PET/CT). Labeled-leukocyte scintigraphy was not reported in any case. Prolonged antibiotic therapy and surgery were found to be the treatment of choice for BGI; however it was not always possible to perform a surgical intervention. Clinical relapses occurred even with a negative PET/CT, while PET/CT consistently positive for BGI occurred in the absence of clinical relapse. This suggests that the use of PET/CT for follow-up is questionable.

Conclusion: Diagnosis of BGI is difficult, due to the combination of clinical, biological, and radiological observations obtained through transesophageal echocardiography and CT. PET/CT is an alternative method to diagnosis BGI, but its impact on clinical management remains unclear. Current data suggests that if surgical replacement of the prosthesis is not possible, patients should be treated with prolonged antibiotic therapy.

Keywords: Bentall prosthesis; Endocarditis; Vascular graft infection.

Copyright © 2017 Elsevier Inc. All rights reserved.

Publication types

• Systematic Review
• Anti-Bacterial Agents / therapeutic use*
• Antifungal Agents / therapeutic use*
• Aorta / surgery
• Aortic Valve / surgery*
• Endocarditis, Bacterial / diagnosis*
• Endocarditis, Bacterial / drug therapy*
• Endocarditis, Bacterial / microbiology
• Heart Valve Prosthesis / microbiology*
• Heart Valve Prosthesis Implantation / adverse effects*
• Middle Aged
• Positron Emission Tomography Computed Tomography
• Retrospective Studies
• Transplants / microbiology
• Anti-Bacterial Agents
• Antifungal Agents