Bentall procedure

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Bentall procedure
Specialty Cardiothoracic surgery, cardiac surgery

The Bentall procedure is a type of cardiac surgery involving composite graft replacement of the aortic valve, aortic root, and ascending aorta, with re-implantation of the coronary arteries into the graft. This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with Marfan syndrome. The Bentall procedure was first described in 1968 by Hugh Bentall and Antony De Bono. [1] It is considered a standard for individuals who require aortic root replacement, and the vast majority of individuals who undergo the surgery receive mechanical valves. [2] [3]

Contents

History

Since its inception, the Bentall procedure has been considered a gold standard of aortic valve replacement.

Types of conduits

Importantly, the use of mechanical vs biologic valves are not predictive of quality of life overall, morbidity and mortality. [5] [6] General guidelines for the repair of valvular heart disease indicate the medical team takes into consideration the following patient factors for the determination of best conduit to use: age, life expectancy, lifestyle choices (diet, exercise, hobbies, risk of potential falls/ physical trauma), medical history (history of stroke or blood clots), likelihood of surgical or transcatheter repeat procedure, and of course patient preference.

Indications and benefits

The Bentall procedure is considered for patients who may have Marfan syndrome, aortic dissection, aortic root aneurysm, aortic regurgitation of the valve. calcification of the aortic valve, and congenital anomalies. [1] [7]

Complications and risks

Early Morbidity and Mortality Within 30 days of hospitalization, morbidity and mortality after Bentall procedure are associated with complications stemming from cardiac arrhythmia, pneumonia, acute respiratory distress syndrome (ARDS), sepsis, graft infection, wound infection, neurologic/ cerebrovascular accident and stroke, hemorrhage/ bleeding, myocardial infarction, pericardial effusion, organ damage/ deterioration. [8] Overall, these complications are seen in < 6% of patients undergoing this procedure, with risk of complications being greatly associated with other preexisting risk factors and comorbidities. [3] [8]

Graft infection and assessment

Like early morbidity and mortality, infection of a graft after Bentall Procedure is rare affecting < 5% of cases, but can be of very serious consequence to the patient. [8] [9] Many of these patients who develop infections have multiple comorbidities and risk factors existing before the surgery including diabetes, suppression of the immune system, preexisting cardiovascular issues outside of the direct indication for a Bentall procedure and cancer. [7]

Graft infection from a Bentall procedure presents similarly to many infections after a major cardiac surgery, with indications in various degrees of severity. Symptoms can include fever, chills, loss of appetite, weight loss, malaise with clinical indications including septic emboli, abscess, left ventricular fistulae, transient ischemic attack. [7] [9] These can occur weeks to years after the Bentall procedure itself.

If a patient is suspected to have a graft infection, they should immediately seek medical attention. Evaluation of an infection may include blood work including CBC, CMP, blood cultures. Further assessment and imaging may involve transesophageal echocardiography, CT scan, CT Angiography, PET scan. [9] [10] Depending on the modality, evidence of infection includes: increased glucose uptake, pseudoaneurysm, fistula, fluid/ attenuation around the graft (indicating increased inflammation), or other increased signs of inflammation around the graft; these findings are then taken into account and assessed in the context of the clinical/ symptomatic picture of the patient. [10]

If a graft infection is highly likely, treatment involves admission to a hospital setting and administration of IV antibiotics. If the infection does not resolve, a graft infection may eventually require either an attempt at graft salvage or a revision surgery for the removal of the infected graft. [10]

Alternatives

Valve sparing aortic root replacement (VSARR) is an alternative procedure to the composite aortic valve graft (CAGVR, Bentall procedure). A notable benefit of VSARR is the reduced need for anticoagulation, as the patient's own aortic valve is spared and does not need to be replaced with a mechanical or bioprosthetic valve. [11]

The VSARR is relatively new compared to the Bentall procedure and is performed about two thirds less often, associated with the increased skill and learning curve needed to navigate the procedure. [11] Additionally, literature overall has shown unclear longevity and longitudinal patient outcomes compared to the Bentall procedure. Recently, there is some evidence VSARR has superior survival rates at 10 and 15 years along with reduced early mortality. [11] Moreover, while there is a decreased reoperation rate in the first 5 years seen with the Bentall procedure, the need for reoperation after Bentall and VSARR are then comparable thereafter. [11]

Vocabulary:

Future directions

Endovascular procedures have been gaining popularity, especially within the last decade, due to their faster healing times and often lower risk of complications. The creation of the Endo-Bentall device showcases a Bentall procedure, but performed in a minimally invasive setting. [13] This is an option for high risk patients otherwise not a candidate for a traditional open procedure. The Endo-Bentall device is made up of three parts: a self-expanding transcatheter aortic valve (TAVR) + aortic endovascular stent graft (TEVAR) and wire-reinforced fenestrations. [13] Candidacy of this procedure is determined by an interdisciplinary team which may include cardiac and vascular surgeons, as well as interventional cardiologists. [14]

There are several limitations of using the Endo-Bentall, including: incorporating coronary arteries, modifying TAVR devices to be better suited for treating aortic valve insufficiency and regurgitation, and addressing a need for dedicated bridging stents. [15]

Beyond the Endo-Bentall, modern literature points to some promising future directions for the repair of the ascending aorta and aortic arch, including: steerable device delivery sheaths, dedicated bridging stents, grafts that can adjust for deployability/ improved positioning, grafts with better anti-embolic protection, left ventricle wires that minimize trauma to the heart, and fusion imaging optimization. [15]

See also

Related Research Articles

<span class="mw-page-title-main">Aortic valve</span> Valve in the human heart between the left ventricle and the aorta

The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. The aortic valve normally has three cusps or leaflets, although in 1–2% of the population it is found to congenitally have two leaflets. The aortic valve is the last structure in the heart the blood travels through before stopping the flow through the systemic circulation.

<span class="mw-page-title-main">Aortic dissection</span> Injury to the innermost layer of the aorta

Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. In most cases, this is associated with a sudden onset of agonizing chest or back pain, often described as "tearing" in character. Vomiting, sweating, and lightheadedness may also occur. Damage to other organs may result from the decreased blood supply, such as stroke, lower extremity ischemia, or mesenteric ischemia. Aortic dissection can quickly lead to death from insufficient blood flow to the heart or complete rupture of the aorta.

<span class="mw-page-title-main">Aneurysm</span> Bulge in the wall of a blood vessel

An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus for clot formation (thrombosis) and embolization. As an aneurysm increases in size, the risk of rupture, which leads to uncontrolled bleeding, increases. Although they may occur in any blood vessel, particularly lethal examples include aneurysms of the circle of Willis in the brain, aortic aneurysms affecting the thoracic aorta, and abdominal aortic aneurysms. Aneurysms can arise in the heart itself following a heart attack, including both ventricular and atrial septal aneurysms. There are congenital atrial septal aneurysms, a rare heart defect.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty of the blood/lymph vessels

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Aortic aneurysm</span> Excessive enlargement of the human aorta

An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. Typically, there are no symptoms except when the aneurysm dissects or ruptures, which causes sudden, severe pain in the abdomen and lower back.

<span class="mw-page-title-main">Thoracic aortic aneurysm</span> Medical condition

A thoracic aortic aneurysm is an aortic aneurysm that presents primarily in the thorax.

Aortic valve replacement is a cardiac surgery procedure whereby a failing aortic valve is replaced with an artificial heart valve. The aortic valve may need to be replaced because of aortic regurgitation, or if the valve is narrowed by stenosis.

<span class="mw-page-title-main">Aortic valve repair</span> Treatment of aortic regurgitation

Aortic valve repair or aortic valve reconstruction is the reconstruction of both form and function of a dysfunctional aortic valve. Most frequently it is used for the treatment of aortic regurgitation. It can also become necessary for the treatment of aortic aneurysm, less frequently for congenital aortic stenosis.

<span class="mw-page-title-main">Valve replacement</span> Replacement of one or more of the heart valves

Valve replacement surgery is the replacement of one or more of the heart valves with either an artificial heart valve or a bioprosthesis. It is an alternative to valve repair.

Valve-sparing aortic root replacement is a cardiac surgery procedure which is used to treat Aortic aneurysms and to prevent Aortic dissection. It involves replacement of the aortic root without replacement of the aortic valve. Two similar procedures were developed, one by Sir Magdi Yacoub, and another by Tirone David.

<span class="mw-page-title-main">Ross procedure</span> Type of cardiac surgical operation

The Ross procedure, also known as pulmonary autograft, is a heart valve replacement operation to treat severe aortic valve disease, such as in children and young adults with a bicuspid aortic valve. It involves removing the diseased aortic valve, situated at the exit of the left side of the heart, and replacing it with the person's own healthy pulmonary valve (autograft), removed from the exit of the heart's right side. To reconstruct the right-sided exit, a pulmonary valve from a cadaver (homograft), or a stentless xenograft, is used to replace the removed pulmonary valve. Compared to a mechanical valve replacement, it avoids the requirement for thinning the blood, has favourable blood flow dynamics, allows growth of the valve with growth of the child and has less risk of endocarditis.

<span class="mw-page-title-main">Annuloaortic ectasia</span> Medical condition

Annuloaortic ectasia is characterized by pure aortic valve regurgitation and aneurysmal dilatation of the ascending aorta. Men are more likely than women to develop idiopathic annuloaortic ectasia, which usually manifests in the fourth or sixth decades of life. Additional factors that contribute to this condition include osteogenesis imperfecta, inflammatory aortic diseases, intrinsic valve disease, Loeys-Dietz syndrome, Marfan syndrome, and operated congenital heart disease.

<span class="mw-page-title-main">Endovascular aneurysm repair</span> Surgery used to treat abdominal aortic aneurysm

Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then specifically termed TEVAR for "thoracic endovascular aortic/aneurysm repair." EVAR involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. In 2003, EVAR surpassed open aortic surgery as the most common technique for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States.

<span class="mw-page-title-main">Randall B. Griepp</span> American cardiothoracic surgeon (1940–2022)

Randall Bertram Griepp was an American cardiothoracic surgeon who collaborated with Norman Shumway in the development of the first successful heart transplant procedures in the U.S. He had an international reputation for contributions to the surgical treatment of aortic aneurysms and aortic dissection and in heart and lung transplantations. He received nearly $8 million in grants from the National Heart, Lung, and Blood Institute.

Minimally invasive cardiac surgery, encompasses various aspects of cardiac surgical procedures that can be performed with minimally invasive approach either via mini-thoracotomy or mini-sternotomy. MICS CABG or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach, and can be performed in patients with multivessel coronary artery disease. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

<span class="mw-page-title-main">Apicoaortic conduit</span> Cardiothoracic surgical process

Apicoaortic Conduit (AAC), also known as Aortic Valve Bypass (AVB), is a cardiothoracic surgical procedure that alleviates symptoms caused by blood flow obstruction from the left ventricle of the heart. Left ventricular outflow tract obstruction (LVOTO) is caused by narrowing of the aortic valve (aortic stenosis) and other valve disorders. AAC, or AVB, relieves the obstruction to blood flow by adding a bioprosthetic valve to the circulatory system to decrease the load on the aortic valve. When an apicoaortic conduit is implanted, blood continues to flow from the heart through the aortic valve. In addition, blood flow bypasses the native valve and exits the heart through the implanted valved conduit. The procedure is effective at relieving excessive pressure gradient across the natural valve. High pressure gradient across the aortic valve can be congenital or acquired. A reduction in pressure gradient results in relief of symptoms.

<span class="mw-page-title-main">Open aortic surgery</span> Surgical technique

Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal, thoracic or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment, usually by the replacement of the affected segment with a prosthetic graft. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States.

<span class="mw-page-title-main">Hans-Joachim Schäfers</span> German surgeon, as well as cardiac, thoracic, and vascular surgeon

Hans-Joachim Schäfers is a German surgeon, as well as cardiac, thoracic, and vascular surgeon and university professor. He is director of the department of Thoracic and Cardiovascular Surgery at the Saarland University Medical Center in Homburg/Saar, Germany. He is known for his activities in aortic valve repair, aortic surgery, and pulmonary endarterectomy.

The Hancock Aortic Tissue Valve is a prosthetic heart valve used in cardiac surgery to replace a damaged or diseased aortic valve. It is a bioprosthetic valve, meaning it is constructed using biological tissues, specifically porcine (pig) valve tissue. This valve is widely utilized in the field of cardiovascular surgery to restore proper blood flow through the heart.

References

  1. 1 2 3 4 Bentall H.; De Bono A. (1968). "A technique for complete replacement of the ascending aorta". Thorax. 23 (4): 338–9. doi:10.1136/thx.23.4.338. PMC   471799 . PMID   5664694.
  2. ↑ Mookhoek, Art; Korteland, Nelleke M.; Arabkhani, Bardia; Di Centa, Isabelle; Lansac, Emmanuel; Bekkers, Jos A.; Bogers, Ad J. J. C.; Takkenberg, Johanna J. M. (2016). "Bentall Procedure: A Systematic Review and Meta-Analysis". Adult Cardiac. 101 (5). The Society of Thoracic Surgeons: 1684–1689. doi: 10.1016/j.athoracsur.2015.10.090 . PMID   26857635.
  3. 1 2 3 Mookhoek, Aart; Korteland, Nelleke M.; Arabkhani, Bardia; Di Centa, Isabelle; Lansac, Emmanuel; Bekkers, Jos A.; Bogers, Ad J.J.C.; Takkenberg, Johanna J.M. (May 2016). "Bentall Procedure: A Systematic Review and Meta-Analysis". The Annals of Thoracic Surgery. 101 (5): 1684–1689. doi:10.1016/j.athoracsur.2015.10.090. PMID   26857635.
  4. ↑ Sá, Michel Pompeu; Tasoudis, Panagiotis; Jacquemyn, Xander; Van den Eynde, Jef; Caranasos, Thomas G.; Ikonomidis, John S.; Chu, Danny; Serna-Gallegos, Derek; Sultan, Ibrahim (2023-09-19). "Long-Term Outcomes of Patients Undergoing Aortic Root Replacement With Mechanical Versus Bioprosthetic Valves: Meta-Analysis of Reconstructed Time-to-Event Data". Journal of the American Heart Association. 12 (18): e030629. doi:10.1161/JAHA.123.030629. ISSN   2047-9980. PMC   10547304 . PMID   37681555.
  5. ↑ Lehr, Eric J.; Wang, Peter Z.T.; Oreopoulos, Antigone; Kanji, Hussein; Norris, Colleen; MacArthur, Roderick (March 2011). "Midterm Outcomes and Quality of Life of Aortic Root Replacement: Mechanical vs Biological Conduits". Canadian Journal of Cardiology. 27 (2): 262.e15–262.e20. doi:10.1016/j.cjca.2010.12.034. PMID   21459276.
  6. ↑ Byrne, J (March 2003). "Biological vs. mechanical aortic root replacement". European Journal of Cardio-Thoracic Surgery. 23 (3): 305–310. doi:10.1016/s1010-7940(02)00816-3. PMID   12614798.
  7. 1 2 3 Machelart, I.; Greib, C.; Wirth, G.; Camou, F.; Issa, N.; Viallard, J.F.; Pellegrin, J.L.; Lazaro, E. (June 2017). "Graft infection after a Bentall procedure: A case series and systematic review of the literature". Diagnostic Microbiology and Infectious Disease. 88 (2): 158–162. doi:10.1016/j.diagmicrobio.2017.03.002. PMID   28330738.
  8. 1 2 3 Joo, Hyun-Chel; Chang, Byung-Chul; Youn, Young-Nam; Yoo, Kyung-Jong; Lee, Sak (2012). "Clinical Experience with the Bentall Procedure: 28 Years". Yonsei Medical Journal. 53 (5): 915. doi:10.3349/ymj.2012.53.5.915. ISSN   0513-5796. PMID   22869473.
  9. 1 2 3 Alavi, Mehrosadat; Abdinejad, Maryam; Rezaei, Mehdi; Moaref, Alireza (January 2024). "Evaluation of vascular graft infection following Bentall surgery using 18F-FDG PET/CT scan: A pediatric case report". Clinical Case Reports. 12 (1): e8396. doi:10.1002/ccr3.8396. ISSN   2050-0904. PMC   10756944 . PMID   38161628.
  10. 1 2 3 Sollini, Martina; Bartoli, Francesco; Boni, Roberto; Zanca, Roberta; Colli, Andrea; Levantino, Maurizio; Menichetti, Francesco; Ferrari, Mauro; Berchiolli, Raffaella; Lazzeri, Elena; Erba, Paola A. (2021-12-01). "Role of Multimodal Imaging in Patients With Suspected Infections After the Bentall Procedure". Frontiers in Cardiovascular Medicine. 8. doi: 10.3389/fcvm.2021.745556 . ISSN   2297-055X. PMC   8671629 . PMID   34926606.
  11. 1 2 3 4 Formica, Francesco; Gallingani, Alan; D'Alessandro, Stefano; Tuttolomondo, Domenico; Hernandez-Vaquero, Daniel; Singh, Gurmeet; Grassa, Giulia; Pattuzzi, Claudia; Maestri, Francesco; Nicolini, Francesco (January 2025). "Long-term outcomes comparison of Bentall-De Bono-versus valve-sparing aortic root replacement: An updated systematic review and reconstructed time-to-event meta-analysis". International Journal of Cardiology. 419: 132728. doi: 10.1016/j.ijcard.2024.132728 . PMID   39551099.
  12. 1 2 Wilson-Smith, Ashley R.; Wilson-Smith, Christian J.; Strode Smith, Jemilla; Ng, Dominic; Muston, Benjamin T.; Eranki, Aditya; Williams, Michael L. (July 2023). "The outcomes of three decades of the David and Yacoub procedures in bicuspid aortic valve patients—a systematic review and meta-analysis". Annals of Cardiothoracic Surgery. 12 (4): 286–294. doi: 10.21037/acs-2023-avs2-19 . PMC   10405344 . PMID   37554710.
  13. 1 2 Ghoreishi, Mehrdad; Chahal, Diljon; Shah, Aakash; Kang, Jeanwan; Hirsch, Jeffrey; Tran, Douglas; McCloskey, Dana; Shkullaku, Melsjan; Gupta, Anuj; Strauss, Erik R.; Dahi, Siamak; Taylor, Bradley S.; Toursavadkohi, Shahab (October 2023). "First-in-Human Endovascular Aortic Root Repair (Endo-Bentall) for Acute Type A Dissection". Circulation: Cardiovascular Interventions. 16 (10): e013348. doi:10.1161/CIRCINTERVENTIONS.123.013348. ISSN   1941-7640. PMID   37737022.
  14. ↑ "Expert Health Care for People of Maryland". www.umms.org. Retrieved 2025-01-12.
  15. 1 2 Gouveia e Melo, Ryan; Stana, Jan; Prendes, Carlota Fernández; Kölbel, Tilo; Peterss, Sven; Stavroulakis, Konstantinous; Rantner, Barbara; Pichlmaier, Maximilian; Tsilimparis, Nikolaos (September 2022). "Current state and future directions of endovascular ascending and arch repairs: The motion towards an endovascular Bentall procedure". Seminars in Vascular Surgery. 35 (3): 350–363. doi:10.1053/j.semvascsurg.2022.07.001. PMID   36153076.


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