What is a Bentall procedure in cardiac surgery?

What is a Bentall Procedure?

The Bentall procedure is a cardiac surgical operation that replaces both the ascending aorta and aortic valve simultaneously using a composite graft (a tube graft with an attached prosthetic valve), with reimplantation of the coronary arteries into the sides of the new graft. 1

Surgical Technique

The procedure involves three key components that are replaced as a single unit:

• Complete removal of the diseased ascending aorta and aortic valve 1
• Insertion of a valved conduit (composite graft-valve device) that contains both a prosthetic valve and tubular graft 1
• Reimplantation of the coronary ostia (the openings where coronary arteries originate) into openings created in the sides of the new graft 1

The prosthetic valve component may be either mechanical or tissue (bioprosthetic), depending on patient factors and surgeon preference 1.

Primary Indications

The Bentall procedure is performed for combined pathology affecting both the aortic root and valve:

• Aortic root aneurysms with concurrent aortic valve disease (most common indication) 1, 2, 3
• Acute type A aortic dissection involving the aortic root with valve dysfunction 1, 2, 3
• Annuloaortic ectasia (dilation of both the aortic annulus and ascending aorta) 3, 4
• Marfan syndrome with aortic root dilation, where composite grafting is specifically recommended 1, 3
• Bicuspid aortic valve disease with ascending aortic aneurysm 5, 3

Technical Evolution

The original Bentall technique described in 1968 has undergone important modifications 1, 6:

• Original method: Coronary ostia remained in continuity with the old aorta and were anastomosed directly to the graft 1
• Button technique (modern standard): Full-thickness "buttons" of aorta surrounding each coronary ostium are excised and reimplanted into openings in the graft, making the procedure technically easier and more reliable 1, 7
• Alternative modifications: Some centers use two separate short 8-mm Dacron grafts for coronary reimplantation 4

Surgical Approach and Timing

Access and urgency considerations include:

• Standard approach: Median sternotomy with cardiopulmonary bypass 2, 7
• Emergency surgery: Performed urgently (often within 24 hours) when acute dissection is complicated by tamponade or hemodynamic instability 2
• Elective surgery: Scheduled when aortic diameter reaches threshold criteria (≥50mm for bicuspid aortic valve, ≥55mm for tricuspid valve) 5

Outcomes and Prognosis

Modern surgical results demonstrate excellent durability:

• Early mortality: 2.3% for elective procedures, but 20% for emergency operations 3
• Long-term survival: Freedom from all-cause mortality at 5,10, and 15 years is 97.1%, 81.9%, and 53.9% respectively 3
• Reoperation rate: Very low, with structural valve dysfunction being rare 3, 4
• Valve-related complications: Linearized rates of major bleeding (1.3%/patient-year), thromboembolism (0.42%/patient-year), and endocarditis (0.22%/patient-year) 4

Critical Predictors of Mortality

Independent risk factors for worse outcomes include:

• Advanced age at time of surgery (OR 1.16 per year) 3
• Emergency surgery (OR 28 compared to elective) 3
• Bicuspid aortic valve (OR 3 compared to tricuspid) 3

Post-Operative Management Considerations

Key management points after Bentall surgery:

• Anticoagulation for mechanical valves: Lifelong vitamin K antagonist (warfarin) therapy is mandatory 1, 5
• Anticoagulation for bioprosthetic valves: Single antiplatelet therapy with low-dose aspirin (75-100mg/day) or oral anticoagulation should be considered for the first 3 months 1
• Surveillance imaging: Transthoracic echocardiography at 1 month to assess valve function and aortic root, then annually for bioprosthetic valves or as clinically indicated for mechanical valves 1

Alternative Approaches

When aortic valve cusps are pliable and structurally normal, experienced centers may offer valve-sparing root replacement techniques (David procedure or Yacoub technique) instead of the Bentall procedure, particularly in young patients to avoid lifelong anticoagulation 1, 5. However, these procedures are more complex and time-consuming, requiring significant surgical expertise 1.