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Bentall Procedure
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In 1968, Bentall and De Bono described a technique for composite aortic valve and root replacement with reimplantation of the coronary arteries. The coronary arteries were sewn to the graft as a side-to-side anastomosis, and the aneurysm wall was wrapped around the graft.
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During the ensuing years, this technique underwent various modifications, primarily because of pseudoaneurysm formation at the side-to-side anastomosis of the coronary button to the graft.
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The Bentall operation currently uses a technique for treating combined disease of the aortic valve and aortic root with an end-to-side coronary button technique, a modification of the original technique described by Kouchoukos et al. in 1991.
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All procedures are performed by creating an open distal anastomosis when there is an inadequate cuff of normal aorta below the cross-clamp or by replacing the entire arch or hemiarch during a period of moderate or deep hypothermic circulatory arrest with antegrade cerebral perfusion or total circulatory arrest with or without retrograde venous perfusion.
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The modified Bentall procedure is the procedure of choice when treating the aortic valve, aortic sinuses, and ascending aorta.
Step 1
Surgical Anatomy
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The pertinent anatomy consists of the aortic valve and related pathology, sinuses of Valsalva, coronary ostia, ascending aorta, and aortic arch. Specific pathologic processes present different challenges in a Bentall procedure. The more common situations are bicuspid aortic valve stenosis (AS) or aortic regurgitation (AR) with a dilated ascending aorta, AR and ascending aortic aneurysm (e.g., Marfan syndrome), and acute or chronic aortic dissection.
Step 2
Preoperative Considerations
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The planning of the procedure requires preoperative echocardiography and cardiac catheterization with coronary angiography and optional aortic root angiography with panning into the aortic arch. A carotid artery Doppler examination may be useful. The use of a contrast magnetic resonance imaging (MRI) or computed tomography (CT) scan with three-dimensional reconstruction is standard to help measure the extent and size of the aneurysm.
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The choice of valve should be determined in consultation with the patient. If there is no associated coronary disease, the procedure can be performed through a ministernotomy. In this case, peripheral venous cannulation is often necessary because of limited access to the right atrial appendage.
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The need for circulatory arrest and possible electroencephalographic monitoring should be determined if the arch is involved or if the aneurysm extends distally to the level of the innominate artery, requiring circulatory arrest to perform an open anastomosis. When circulatory arrest is required, decisions about cerebral protection need to be made with regard to technique, cardiopulmonary bypass (CPB) setup, temperature, and antegrade perfusion.
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A plan for cardioplegia administration is essential, especially if a ministernotomy is to be used. I prefer antegrade and retrograde del Nido blood cardioplegia readministered every 60 to 90 minutes.
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Special consideration is given to the treatment of postprocedure coagulopathy. Administration platelets, coagulation factors, and possible factor VII may be necessary. I use heparin-coated CPB circuits. In addition, a Rotem device (Tem International, Basel, Switzerland) is used to guide component therapy for postoperative coagulation.
Step 3
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