The Bentall procedure is a type of cardiac surgery involving composite graft replacement of the

aortic valve The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. ...

, aortic root, and

ascending aorta The ascending aorta (AAo) is a portion of the aorta commencing at the upper part of the base of the left ventricle, on a level with the lower border of the third costal cartilage behind the left half of the sternum. Structure It passes obliqu ...

, with re-implantation of the

coronary arteries The coronary arteries are the arteries, arterial blood vessels of coronary circulation, which transport oxygenated blood to the Cardiac muscle, heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any ...

into the graft. This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with

Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with dolichostenomelia, long arms, legs, Arachnodactyly, fingers, and toes. They also typically ha ...

. The Bentall procedure was first described in 1968 by Hugh Bentall and Antony De Bono. It is considered a standard for individuals who require aortic root replacement, and the vast majority of individuals who undergo the surgery receive mechanical valves.

History

Since its inception, the Bentall procedure has been considered a gold standard of aortic valve replacement.

Types of conduits

* Mechanical valves - The majority of cases utilize mechanical valves because of its long term durability, improved probability of long term survival, and decreased need for reoperation. Notably, these do require life-long anticoagulation to minimize the risk of blood clots, which has an increased risk of bleeding. * Biological/ bioprosthetic - Not as often used due to the increased likelihood of needing a repeat graft replacement from decreased longitudinal durability. However, usually does not require lifelong coagulation, making it a considerable option for patients with an increased fall or bleeding risk. Importantly, the use of mechanical vs biologic valves are not predictive of quality of life overall, morbidity and mortality. General guidelines for the repair of valvular heart disease indicate the medical team takes into consideration the following patient factors for the determination of best conduit to use: age, life expectancy, lifestyle choices (diet, exercise, hobbies, risk of potential falls/ physical trauma), medical history (history of stroke or blood clots), likelihood of surgical or transcatheter repeat procedure, and of course patient preference.

Indications and benefits

The Bentall procedure is considered for patients who may have Marfan syndrome, aortic dissection, aortic root aneurysm, aortic regurgitation of the valve, calcification of the aortic valve, and congenital anomalies.

Complications and risks

Early Morbidity and Mortality Within 30 days of hospitalization, morbidity and mortality after Bentall procedure are associated with complications stemming from

cardiac arrhythmia Arrhythmias, also known as cardiac arrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. Essentially, this is anything but normal sinus rhythm. A resting heart rate that is too fast – above 100 beat ...

pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...

, acute respiratory distress syndrome (ARDS),

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

, graft infection, wound infection, neurologic/ cerebrovascular accident and

stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...

, hemorrhage/ bleeding,

myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when Ischemia, blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom ...

pericardial effusion A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous Connective tissue, connective membrane and an inner two-layered serous membrane ...

, organ damage/ deterioration. Overall, these complications are seen in < 6% of patients undergoing this procedure, with risk of complications being greatly associated with other preexisting risk factors and comorbidities.

Graft infection and assessment

Like early morbidity and mortality, infection of a graft after Bentall Procedure is rare affecting < 5% of cases, but can be of very serious consequence to the patient. Many of these patients who develop infections have multiple comorbidities and risk factors existing before the surgery including diabetes, suppression of the immune system, preexisting cardiovascular issues outside of the direct indication for a Bentall procedure and cancer. Graft infection from a Bentall procedure presents similarly to many infections after a major cardiac surgery, with indications in various degrees of severity. Symptoms can include fever, chills, loss of appetite, weight loss, malaise with clinical indications including septic emboli, abscess, left ventricular fistulae, transient ischemic attack. These can occur weeks to years after the Bentall procedure itself. If a patient is suspected to have a graft infection, they should immediately seek medical attention. Evaluation of an infection may include blood work including

CBC CBC may refer to: Media * Cadena Baja California or Grupo Cadena, a radio and television broadcaster in Mexico * Canadian Broadcasting Corporation, Canada's radio and television public broadcaster ** CBC Television ** CBC Radio One ** CBC Music ** ...

, CMP,

blood culture A blood culture is a medical laboratory test used to detect bacteria or fungi in a person's blood. Under normal conditions, the blood does not contain microorganisms: their presence can indicate a bloodstream infection such as bacteremia or ...

s. Further assessment and imaging may involve transesophageal echocardiography,

CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

, CT Angiography,

PET scan Positron emission tomography (PET) is a functional imaging technique that uses radioactive substances known as radiotracers to visualize and measure changes in Metabolism, metabolic processes, and in other physiological activities including bloo ...

. Depending on the modality, evidence of infection includes: increased glucose uptake,

pseudoaneurysm A pseudoaneurysm, also known as a false aneurysm, is a locally contained hematoma outside an artery or the heart due to damage to the vessel wall. The injury passes through all three layers of the arterial wall, causing a leak, which is contai ...

, fistula, fluid/ attenuation around the graft (indicating increased inflammation), or other increased signs of inflammation around the graft; these findings are then taken into account and assessed in the context of the clinical/ symptomatic picture of the patient. If a graft infection is highly likely, treatment involves admission to a hospital setting and administration of IV antibiotics. If the infection does not resolve, a graft infection may eventually require either an attempt at graft salvage or a revision surgery for the removal of the infected graft.

Alternatives

Valve sparing aortic root replacement (VSARR) is an alternative procedure to the composite aortic valve graft (CAGVR, Bentall procedure). A notable benefit of VSARR is the reduced need for anticoagulation, as the patient's own aortic valve is spared and does not need to be replaced with a mechanical or bioprosthetic valve. The VSARR is relatively new compared to the Bentall procedure and is performed about two thirds less often, associated with the increased skill and learning curve needed to navigate the procedure. Additionally, literature overall has shown unclear longevity and longitudinal patient outcomes compared to the Bentall procedure. Recently, there is some evidence VSARR has superior survival rates at 10 and 15 years along with reduced early mortality. Moreover, while there is a decreased reoperation rate in the first 5 years seen with the Bentall procedure, the need for reoperation after Bentall and VSARR are then comparable thereafter. Vocabulary: * Yacoub procedure - Aorta is remodeled. Consider for older people and aneurysms not caused by a genetic disorder. * David procedure - Uses complex techniques. Reimplant aortic valve. Useful for younger patients. Also useful for people with a genetic cause of heart syndromes like bicuspid aortic valve.

Future directions

Endovascular procedures have been gaining popularity, especially within the last decade, due to their faster healing times and often lower risk of complications. The creation of the Endo-Bentall device showcases a Bentall procedure, but performed in a minimally invasive setting. This is an option for high risk patients otherwise not a candidate for a traditional open procedure. Based on the case reports identified in the current literature, two concepts of Endobentall have emerged; the first involves using a balloon-expandable valve in combination with a tubular graft across the left ventricular outflow tract (LVOT), either as a one-stage or two-stage device. The second concept is a physician-constructed self-expandable valve conduit. Candidacy of this procedure is determined by an interdisciplinary team which may include cardiac and vascular surgeons, as well as interventional cardiologists. The ascending aorta presents numerous challenges for endovascular intervention due to its proximity to critical structures including the sinotubular junction, aortic valve, coronary ostia, and arch vessels as well as its short length, variable wall elasticity, high-pressure flow, elevated shear stress, turbulence, and complex dynamic motion with rotational forces.doi: 10.1016/j.ejvs.2024.10.049. Beyond the Endo-Bentall, modern literature points to some promising future directions for the repair of the ascending aorta and aortic arch, including: steerable device delivery sheaths, dedicated bridging stents, grafts that can adjust for deployability/ improved positioning, grafts with better anti-embolic protection, left ventricle wires that minimize trauma to the heart, and fusion imaging optimization.

References

External links

* ''Cardiac Surgery in the Adult'
Ascending Aortic Aneurysms

{{cardiac surgery Cardiac surgery