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Bentall Procedure

What is the Bentall procedure?

Bentall procedure is a cardiac procedure that was introduced by H Bentall and A De Bono in 1968. It is performed to repair or replace an aortic root, aortic valve, or ascending aortic root lesion. A composite aortic valve graft and ascending aortic graft are used to replace the aortic valve and the aortic root which is later linked to the coronary arteries by anastomosis. 

Why is it recommended?

The procedure is a gold standard intervention recommended for patients with root and ascending aortic aneurysm associated with aortic valve regurgitation. It is also performed in patients with aortic dissection. In this condition, the inner layer of the aorta tears. 

How is the procedure performed?

Bentall procedures were introduced by H Bentall and A De Bono in 1968. Since its introduction, the procedure has been modified a couple of times to be more effective. The original procedure used a composite mechanical valve conduit but did not remove the entire diseased aorta and did not make the coronary buttons so the complication rate was high. Therefore, the procedure is modified to make the coronary buttons and remove all the diseased ascending aortic tissue. In the modified procedure, a full-thickness "button" of the aorta surrounding the coronary Ostia is removed to maintain the circulation in the coronary artery. This process makes it easier for implanting the proximal end of the coronary arteries into openings made in the aortic vascular graft. It can be done using a mechanical prosthetic graft in which case anticoagulants have to be taken for the entire life or can be done using a biological composite graft in which case a biological valve is used and anticoagulants can be stopped after 3 months and the patient remains on antiplatelets only. 

The steps followed during a modified Bentall’s technique include: 

  • The procedure is performed under general anaesthesia.

  • A median sternotomy approach is used to reach the heart and aorta.

  • It involves cardiopulmonary bypass. 

  • The ascending aorta is cross clamped.

  • The aneurysm is opened, and myocardial protection is accomplished by delivering blood cardioplegia solution. This is done to reduce the reperfusion injury that may occur after the removal of the aortic cross-clamp.

  • The native aortic valve is inspected, isolated from the surrounding tissue, and removed.

  • The left, as well as the right coronary ostium, is identified and the buttons are made and left suspended. 

  • The remaining aortic root is removed. 

  • A new aortic root prosthesis is implanted.  

  • The coronary ostium is re-implanted into the aortic root.

  • The heart is de-aired, and the coronary cross-clamp is removed.

The type of aortic root substitutes include:

  • The freestyle bioprosthesis is a porcine aortic root that is ligated or joined to the coronary arteries.

  • The Valsalva graft is a prefabricated biological aortic valved conduit. It is a combination of a porcine stentless biological valve and a triple-layered vascular graft.

  • Composite mechanical valve conduit 

Advantages of the procedure:

  • The biological valve prostheses used in the Bentall procedures are superior and more durable. 

  • There is no need for the use of blood thinners when the biological prosthesis is used. 


What are the risks of Bentall’s procedure?

Any surgical procedure is associated with some risks and these can be reversible or irreversible. The risks associated with Bentall’s procedure include: 

  • Internal or external bleeding

  • Low cardiac output

  • Arrhythmias (abnormal heartbeat) 

  • Diffuse cerebral hypoxia 

  • Short term memory problems, blurring of the vision, unable to concentrate.  

  • Infection (incision site infection, sepsis, etc.)

  • Renal failure that may need hemodialysis. 

  • Lung problems

  • Cardiac problems like stroke, heart attack, etc.

  • Blood clot in lung or legs

  • Death

What to expect from the procedure? 

Bentall procedure or an aortic root replacement is performed to treat a larger ascending aorta aneurysm. Aneurysm if left untreated, may burst, and may have adverse outcomes. Bentall is a life-saving intervention performed to prevent an aneurysm from bursting (as a pre-planned procedure) and also if an aneurysm has already ruptured (under emergency condition). During the procedure, an incision in the middle of the chest is made to access the aorta. A heart-Lung bypass machine is used, and the heart is temporarily stopped. The defective part of the aorta, as well as the faulty valves, are removed. A synthetic graft attached to a bio-prosthetic valve is stitched to the aorta. Coronary arteries are then attached to the two openings made in the artificial graft. The incision is closed and dressed. The entire procedure may last for about 5 hours. Post-surgery, the patient will be able to lead a normal life. The procedure offers a higher survival rate and also offers relief from aorta problems for a longer time.    

Frequently Asked Questions:

1. How long does a Bentall procedure take?

The entire Bentall procedure takes about 5 hours long. 

2. What is a modified Bentall procedure?

The original procedure used a composite mechanical valve conduit but did not remove the entire diseased aorta and did not make the coronary buttons so the complication rate was high. Therefore, the procedure is modified to make the coronary buttons and remove all the diseased ascending aortic tissue. In the modified procedure, a full-thickness "button" of the aorta surrounding the coronary Ostia is removed to maintain the circulation in the coronary artery. This process makes it easier for implanting the proximal end of the coronary arteries into openings made in the aortic vascular graft. It can be done using a mechanical prosthetic graft in which case anticoagulants have to be taken for the entire life or can be done using biological composite graft in which case a biological valve is used and anticoagulants can be stopped after 3 months and the patient remains on antiplatelets only. 

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