How is the Bentall procedure performed?

How the Bentall Procedure is Performed

The Bentall procedure involves complete replacement of the ascending aorta and aortic valve with a composite valved conduit (graft-valve device), followed by reimplantation of the coronary ostia into openings created in the sides of the new graft. 1, 2

Surgical Access and Setup

• Median sternotomy is the standard approach for accessing the ascending aorta and aortic root 1
• The pericardial incision is initiated in the midline inferiorly to avoid the friable dissected ascending aorta in acute dissection cases 1
• Extracorporeal circulation is established by cannulating one femoral artery and the right atrium 1
• Once on bypass, the aorta is mobilized to visualize the origin of the innominate artery and the aortic root 1

Core Surgical Steps

1. Removal of Diseased Structures

• The diseased ascending aorta and aortic valve are completely excised 2, 3
• The dissected layers around the sinuses and coronary ostia are removed, leaving the valve cusps and their insertion lines intact when possible 1

2. Composite Graft Insertion

• A valved conduit (composite graft-valve device) is selected, which may contain either a mechanical or tissue prosthetic valve 1, 2
• Transmural mattress sutures are placed through the aortic annulus 1
• These annular sutures are then passed through the cardiac end of the prosthetic graft 1
• The graft is secured to the left ventricular outflow tract proximally 1

3. Coronary Artery Reimplantation (Button Technique)

• The coronary ostia are excised in button form (circular segments of aortic wall containing the coronary openings) 1, 4
• Openings are created in the sides of the conduit at appropriate locations 1, 2
• The coronary buttons are anastomosed directly to these openings in the graft 1, 4
• This "button technique" is the most commonly used modification and helps reduce postoperative bleeding complications 4

4. Distal Anastomosis

• The distal end of the tube graft is anastomosed to the uninvolved ascending aorta in limited dissections 1
• In most cases, replacement extends to the junction of the ascending aorta and arch or beyond 1
• The graft is attached to the ascending aorta distally 1

Technical Considerations

Valve Selection

• Mechanical valves require lifelong anticoagulation but offer durability 1, 2
• Bioprosthetic (tissue) valves avoid lifelong anticoagulation but may have limited durability, particularly in younger patients 1, 2
• The choice depends on patient age, bleeding risk, and ability to comply with anticoagulation 1

Coronary Ostia Management

• If the coronary ostia are close to the aortic annulus and a stiffened aortic wall creates tension, they must be excised in button form before anastomosis 1
• If dissection has reached an ostium without disrupting the coronary vessel, the ostium can usually be preserved 1
• An ostium completely surrounded by dissected aortic wall should be excised in button form 1

Common Pitfalls and How to Avoid Them

• Coronary ostial tension: When the aortic wall is stiffened or the ostia are positioned close to the annulus, direct anastomosis creates dangerous tension—always use the button technique in these cases 1
• Postoperative bleeding: The button technique modification significantly reduces this complication compared to the original Bentall-De Bono method 4
• Coronary obstruction: Patients are at risk for proximal coronary artery obstruction or kinking post-operatively—meticulous attention to coronary button positioning and tension-free anastomosis is critical 1
• Inadequate distal extent: In acute dissections, ensure the distal anastomosis extends to healthy, non-dissected aorta to prevent recurrent dissection 1

Specific Clinical Scenarios

Acute Type A Dissection with Ectatic Root

• In patients with previously ectatic proximal aorta (including most Marfan syndrome patients), composite graft implantation is mandatory 1
• The Bentall procedure is less complicated and time-consuming than valve-sparing operations in the emergency setting 1, 5

Elective Surgery in Marfan Syndrome

• The modified Bentall procedure (composite valved graft conduit) is one of the two most commonly performed aortic root replacements in the United States for Marfan patients 1
• Surgical risk is very low when performed by experienced surgeons in Multidisciplinary Aortic Teams 1