What is a Bio-Bentall Procedure?
A Bio-Bentall procedure is a surgical technique for complete aortic root replacement using a composite graft consisting of a bioprosthetic (biological tissue) aortic valve sewn into a synthetic vascular tube (Dacron graft), with reimplantation of the coronary arteries into the graft.
Surgical Technique
The Bio-Bentall is a modification of the original Bentall procedure, where instead of using a mechanical valve, surgeons use a biological valve prosthesis. The procedure involves:
- Complete removal of the diseased aortic root and ascending aorta
- Implantation of a composite graft (bioprosthetic valve + Dacron tube graft)
- Reimplantation of both coronary arteries into the graft
- Attachment of the graft proximally to the left ventricular outflow tract and distally to the ascending aorta
Modern techniques often use pre-manufactured Valsalva grafts (such as J Graft Valsalva) combined with bioprosthetic valves like Magna EASE, Inspiris, Trifecta, or Avalus 1.
Key Distinction from Standard Bentall
The critical difference between a Bio-Bentall and the traditional modified Bentall procedure is the valve type:
- Modified Bentall: Uses a mechanical prosthetic valve (requires lifelong anticoagulation)
- Bio-Bentall: Uses a bioprosthetic valve (avoids lifelong anticoagulation but has limited durability)
2 describes the modified Bentall as typically using a mechanical valve, though bioprosthetic options exist.
Clinical Indications
The Bio-Bentall is performed for:
- Aortic root aneurysms with ascending aorta involvement
- Severe aortic valve disease combined with aortic root pathology
- Marfan syndrome with aortic root dilatation
- Aortic dissection involving the root
Outcomes and Considerations
In patients over 65 years of age, the Bio-Bentall procedure demonstrates excellent surgical and long-term outcomes 1. Key data include:
- Hospital mortality: 3-8% depending on urgency 1, 3
- Long-term survival: 83.6% at 7 years in elderly patients 1
- Freedom from structural valve deterioration: 100% in mid-term follow-up 1
- Comparable outcomes to isolated biological aortic valve replacement 3
Advantages of Bio-Bentall:
- No lifelong anticoagulation required (major benefit over mechanical Bentall)
- Lower cerebral embolism rates compared to mechanical valves 3
- Excellent outcomes in patients >65 years 1
Important Caveats:
- Bioprosthetic valve durability is limited (typically 10-15 years), requiring consideration of patient age and life expectancy
- In younger patients who may outlive the valve, valve-in-valve procedures should be planned for the future 1
- The flanged technique allows use of larger prostheses, potentially improving durability 4
Technical Variations
The procedure can be performed through:
- Standard median sternotomy (gold standard approach)
- Minimally invasive right anterolateral minithoracotomy in selected patients 5
- May include concomitant procedures like coronary artery bypass grafting or hemiarch replacement 1
The Bio-Bentall is particularly appropriate for older patients (≥65 years) who prioritize avoiding anticoagulation and are less likely to outlive the bioprosthetic valve, while younger patients may benefit more from valve-sparing root replacement (David procedure) or mechanical valve options 2.