What is a Bentall Procedure?
The Bentall procedure is a surgical operation that replaces the aortic root, ascending aorta, and aortic valve using a composite graft (prosthetic valve sewn to a synthetic tube graft), with reimplantation of the coronary arteries into the graft. 1
Surgical Technique
The procedure involves:
- Composite graft construction: A prosthetic aortic valve (typically mechanical, though bioprosthetic valves can be used) is attached to a synthetic aortic graft 1
- Coronary reimplantation: The coronary arteries are reimplanted into the graft using the "button technique" - removing full-thickness "buttons" of aorta surrounding the coronary ostia and sewing them into openings created in the synthetic graft 2
- Proximal attachment: The graft is secured to the left ventricular outflow tract
- Distal attachment: The graft is connected to the ascending aorta
- Surgical approach: Performed through median sternotomy under cardiopulmonary bypass 2
This modified approach (often called the "modified Bentall procedure") replaced the original technique and makes coronary reimplantation technically easier and more reliable 2.
Clinical Indications
The Bentall procedure is indicated when patients have combined pathology affecting both the aortic valve and aortic root:
- Aortic root aneurysms with aortic valve disease (stenosis or regurgitation)
- Ascending aortic aneurysms extending below the sinotubular junction with valve involvement 3
- Less commonly, aortic dissection affecting the aortic root and valve 2
- Aortic valve endocarditis with root involvement 4
Common underlying conditions include:
- Marfan syndrome 1, 5
- Bicuspid aortic valve disease 6
- Degenerative aortic disease 6
- Takayasu's arteritis 4
When to Choose Bentall vs. Valve-Sparing Surgery
According to current guidelines, the choice depends on valve quality 3:
- Bentall procedure: Indicated when the aortic valve cusps are diseased, calcified, or not suitable for preservation 3
- Valve-sparing procedures (David or Yacoub techniques): May be performed by experienced centers when valve cusps are pliable and healthy 1, 3
The advantage of valve-sparing surgery is avoiding lifelong prosthetic valve complications, but durability remains a concern (7% developed moderate or greater aortic regurgitation at 1 year in Marfan patients) 1. The Bentall procedure remains the gold standard when valve preservation is not feasible 7.
Outcomes and Prognosis
Modern surgical results are excellent when performed by experienced teams 1, 3:
- Early mortality: 4.5% overall, but only 2.3% for elective cases 6; experienced centers report <1% mortality 3
- 30-day mortality: Zero in recent minimally invasive series 8
- Long-term survival: 95% at 5 years and 93% at 8 years 9
- Freedom from reoperation: Very low rates, with annual reoperation risk of 0.46% per patient-year 7
Predictors of worse outcomes include:
Post-Operative Management
Key management points 3:
- Anticoagulation: For mechanical valves, lifelong warfarin is required
- For bioprosthetic valves: Consider single antiplatelet therapy (aspirin 75-100 mg daily) or anticoagulation for the first 3 months post-operatively 3
- Surveillance imaging:
- TTE at discharge and 1 month
- If aorta fully repaired: Follow-up at 2 years, then every 5 years
- If residual aortic disease: More frequent surveillance per aneurysm protocols 3
Long-Term Complications
Annual linearized rates from meta-analysis 7:
- Late mortality: 2.02% per patient-year
- Major bleeding: 0.64% per patient-year
- Thromboembolism: 0.77% per patient-year
- Endocarditis: 0.39% per patient-year
- Major adverse valve-related events: 2.66% per patient-year
These complication rates highlight why valve-sparing surgery is increasingly preferred when technically feasible, though the Bentall procedure remains highly durable with decreasing reoperation rates over time 7.
Emerging Techniques
Minimally invasive approaches via right anterior mini-thoracotomy with 3D visualization are being developed, showing feasibility in selected patients with experienced teams, though this remains investigational 8. The endovascular "Endo-Bentall" procedure is also emerging but remains experimental with very limited clinical data 10.