Bentall procedure

Short description: Type of heart surgery

Bentall procedure

Specialty| cardiothoracic surgery, cardiac surgery

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The Bentall procedure is a type of cardiac surgery involving composite graft replacement of the aortic valve, aortic root, and ascending aorta, with re-implantation of the coronary arteries into the graft. This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with Marfan syndrome. The Bentall procedure was first described in 1968 by Hugh Bentall and Antony De Bono.[1] 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.[2][3]

## Contents

* 1 History
* 1.1 Types of conduits
* 2 Indications and benefits
* 3 Complications and risks
* 3.1 Graft infection and assessment
* 4 Alternatives
* 5 Future directions
* 6 See also
* 7 References
* 8 External links

## 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.[3][4]
* 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 anticoagulation, 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.[5][6] 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.[1][7]

## 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, pneumonia, acute respiratory distress syndrome (ARDS), sepsis, graft infection, wound infection, neurologic/ cerebrovascular accident and stroke, hemorrhage/ bleeding, myocardial infarction, pericardial effusion, organ damage/ deterioration.[8] 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.[3][8]

### 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.[8][9] 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.[7]

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.[7][9] 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, CMP, blood cultures. Further assessment and imaging may involve transesophageal echocardiography, CT scan, CT Angiography, PET scan.[9][10] Depending on the modality, evidence of infection includes: increased glucose uptake, pseudoaneurysm, 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.[10]

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.[10]

## 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.[11]

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.[11] 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.[11] 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.[11]

Vocabulary:

* Yacoub procedure - Aorta is remodeled. Consider for older people and aneurysms not caused by a genetic disorder.[1][12]
* 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.[1][12]

## 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.[13] 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.[14][15][16] The second concept is a physician-constructed self-expandable valve conduit.[17]

Candidacy of this procedure is determined by an interdisciplinary team which may include cardiac and vascular surgeons, as well as interventional cardiologists.[18]

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.[19][20]

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.[20]

## See also

* Aortic valve replacement
* Marfan syndrome
* Ross procedure
* Valve-sparing aortic root replacement
* Open aortic surgery
* Endovascular aneurysm repair

## References

1. ↑ 1.0 1.1 1.2 1.3 Bentall H.; De Bono A. (1968). "A technique for complete replacement of the ascending aorta". Thorax 23 (4): 338–9. doi:10.1136/thx.23.4.338. PMID 5664694.
2. ↑ Mookhoek, Art; Korteland, Nelleke M.; Arabkhani, Bardia; Di Centa, Isabelle; Lansac, Emmanuel; Bekkers, Jos A.; Bogers, Ad J. J. C.; Takkenberg, Johanna J. M. (2016). "Bentall Procedure: A Systematic Review and Meta-Analysis". Adult Cardiac (The Society of Thoracic Surgeons) 101 (5): 1684–1689. doi:10.1016/j.athoracsur.2015.10.090. PMID 26857635. https://www.annalsthoracicsurgery.org/article/S0003-4975(15)01762-2/pdf.
3. ↑ 3.0 3.1 3.2 Mookhoek, Aart; Korteland, Nelleke M.; Arabkhani, Bardia; Di Centa, Isabelle; Lansac, Emmanuel; Bekkers, Jos A.; Bogers, Ad J.J.C.; Takkenberg, Johanna J.M. (May 2016). "Bentall Procedure: A Systematic Review and Meta-Analysis" (in en). The Annals of Thoracic Surgery 101 (5): 1684–1689. doi:10.1016/j.athoracsur.2015.10.090. PMID 26857635. https://linkinghub.elsevier.com/retrieve/pii/S0003497515017622.
4. ↑ Sá, Michel Pompeu; Tasoudis, Panagiotis; Jacquemyn, Xander; Van den Eynde, Jef; Caranasos, Thomas G.; Ikonomidis, John S.; Chu, Danny; Serna-Gallegos, Derek et al. (2023-09-19). "Long-Term Outcomes of Patients Undergoing Aortic Root Replacement With Mechanical Versus Bioprosthetic Valves: Meta-Analysis of Reconstructed Time-to-Event Data" (in en). Journal of the American Heart Association 12 (18). doi:10.1161/JAHA.123.030629. ISSN 2047-9980. PMID 37681555.
5. ↑ Lehr, Eric J.; Wang, Peter Z.T.; Oreopoulos, Antigone; Kanji, Hussein; Norris, Colleen; MacArthur, Roderick (March 2011). "Midterm Outcomes and Quality of Life of Aortic Root Replacement: Mechanical vs Biological Conduits" (in en). Canadian Journal of Cardiology 27 (2): 262.e15–262.e20. doi:10.1016/j.cjca.2010.12.034. PMID 21459276. https://linkinghub.elsevier.com/retrieve/pii/S0828282X10000504.
6. ↑ Byrne, J (March 2003). "Biological vs. mechanical aortic root replacement" (in en). European Journal of Cardio-Thoracic Surgery 23 (3): 305–310. doi:10.1016/s1010-7940(02)00816-3. PMID 12614798. https://academic.oup.com/ejcts/article-lookup/doi/10.1016/s1010-7940(02)00816-3.
7. ↑ 7.0 7.1 7.2 Machelart, I.; Greib, C.; Wirth, G.; Camou, F.; Issa, N.; Viallard, J.F.; Pellegrin, J.L.; Lazaro, E. (June 2017). "Graft infection after a Bentall procedure: A case series and systematic review of the literature" (in en). Diagnostic Microbiology and Infectious Disease 88 (2): 158–162. doi:10.1016/j.diagmicrobio.2017.03.002. PMID 28330738. https://linkinghub.elsevier.com/retrieve/pii/S0732889317300780.
8. ↑ 8.0 8.1 8.2 Joo, Hyun-Chel; Chang, Byung-Chul; Youn, Young-Nam; Yoo, Kyung-Jong; Lee, Sak (2012). "Clinical Experience with the Bentall Procedure: 28 Years" (in en). Yonsei Medical Journal 53 (5): 915. doi:10.3349/ymj.2012.53.5.915. ISSN 0513-5796. PMID 22869473. https://eymj.org/DOIx.php?id=10.3349/ymj.2012.53.5.915.
9. ↑ 9.0 9.1 9.2 Alavi, Mehrosadat; Abdinejad, Maryam; Rezaei, Mehdi; Moaref, Alireza (January 2024). "Evaluation of vascular graft infection following Bentall surgery using 18F-FDG PET/CT scan: A pediatric case report" (in en). Clinical Case Reports 12 (1). doi:10.1002/ccr3.8396. ISSN 2050-0904. PMID 38161628.
10. ↑ 10.0 10.1 10.2 Sollini, Martina; Bartoli, Francesco; Boni, Roberto; Zanca, Roberta; Colli, Andrea; Levantino, Maurizio; Menichetti, Francesco; Ferrari, Mauro et al. (2021-12-01). "Role of Multimodal Imaging in Patients With Suspected Infections After the Bentall Procedure". Frontiers in Cardiovascular Medicine 8. doi:10.3389/fcvm.2021.745556. ISSN 2297-055X. PMID 34926606.
11. ↑ 11.0 11.1 11.2 11.3 Formica, Francesco; Gallingani, Alan; D'Alessandro, Stefano; Tuttolomondo, Domenico; Hernandez-Vaquero, Daniel; Singh, Gurmeet; Grassa, Giulia; Pattuzzi, Claudia et al. (January 2025). "Long-term outcomes comparison of Bentall-De Bono-versus valve-sparing aortic root replacement: An updated systematic review and reconstructed time-to-event meta-analysis" (in en). International Journal of Cardiology 419. doi:10.1016/j.ijcard.2024.132728. PMID 39551099. https://linkinghub.elsevier.com/retrieve/pii/S0167527324013500.
12. ↑ 12.0 12.1 Wilson-Smith, Ashley R.; Wilson-Smith, Christian J.; Strode Smith, Jemilla; Ng, Dominic; Muston, Benjamin T.; Eranki, Aditya; Williams, Michael L. (July 2023). "The outcomes of three decades of the David and Yacoub procedures in bicuspid aortic valve patients—a systematic review and meta-analysis". Annals of Cardiothoracic Surgery 12 (4): 286–294. doi:10.21037/acs-2023-avs2-19. PMID 37554710.
13. ↑ Ghoreishi, Mehrdad; Chahal, Diljon; Shah, Aakash; Kang, Jeanwan; Hirsch, Jeffrey; Tran, Douglas; McCloskey, Dana; Shkullaku, Melsjan et al. (October 2023). "First-in-Human Endovascular Aortic Root Repair (Endo-Bentall) for Acute Type A Dissection" (in en). Circulation: Cardiovascular Interventions 16 (10). doi:10.1161/CIRCINTERVENTIONS.123.013348. ISSN 1941-7640. PMID 37737022. https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.123.013348.
14. ↑ doi: 10.1016/j.jaccas.2019.11.071. eCollection 2020 Mar.
15. ↑ doi: 10.1177/15266028211065959. Epub 2021 Dec 29.
16. ↑ doi: 10.1161/CIRCINTERVENTIONS.122.012848. Epub 2023 Apr 3.
17. ↑ doi: 10.1161/CIRCINTERVENTIONS.123.013348.
18. ↑ "Expert Health Care for People of Maryland" (in en). https://www.umms.org/.
19. ↑ doi: 10.1016/j.ejvs.2024.10.049.
20. ↑ 20.0 20.1 Gouveia e Melo, Ryan; Stana, Jan; Prendes, Carlota Fernández; Kölbel, Tilo; Peterss, Sven; Stavroulakis, Konstantinous; Rantner, Barbara; Pichlmaier, Maximilian et al. (September 2022). "Current state and future directions of endovascular ascending and arch repairs: The motion towards an endovascular Bentall procedure" (in en). Seminars in Vascular Surgery 35 (3): 350–363. doi:10.1053/j.semvascsurg.2022.07.001. PMID 36153076. https://linkinghub.elsevier.com/retrieve/pii/S089579672200045X.

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