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How-to-do-it

Modified Bentall operation: the double sewing ring technique

Department Cardiovascular Surgery, Villa Maria Cecilia Hospital, Via Corriera 1, Cotignola, Lugo (RA), Italy

Received 12 May 2007; received in revised form 11 July 2007; accepted 11 July 2007.

^_* Corresponding author. Address: Via Battuti Verdi 1, 47100, Forlì (FC), Italy. Tel.: +39 0543 347141; fax: +39 0543 34742. (Email: dellamore76{at}libero.it).

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
The Bentall–DeBono operation is the technique of choice for aortic root replacement. As more patients do not accept or have contraindications to lifelong anticoagulation, the biological Bentall operation is a good option for these patients, even though complex reoperations would then be required for bioprosthesis degeneration. We studied a modified technique to simplify the reoperations in patients undergoing biological Bentall procedure. A bioprosthetic valved conduit was obtained creating two separate sewing rings at different levels of the vascular graft. One ring was used to sew the bioprosthesis on the vascular graft. The second ring was used to fix the vascular graft on the native aortic annulus. In case of reoperation, the bioprosthesis could be removed cutting only the suture on the first ring. Then the same ring could be used to fix the new prosthesis. Since 2006, we have performed 12 biological Bentall operations with our modification. The mean age was 63.2 years (range 43–77 years), the mean cardiopulmonary time was 79 ± 12 min and the mean aortic cross-clamping time was 68 ± 10 min. We had no in-hospital mortality; the postoperative period was uneventful in all patients. In our experience this modification seems to be simple and reproducible, without increasing the operative risk and postoperative morbidity.

Key Words: Aorta • Aneurysm • Cardiovascular disease • Valvular prosthesis

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
A Bentall–DeBono operation is the technique of choice for aortic root replacement [1]. The commercially available valved conduits employing mechanical valves require lifelong anticoagulation. Alternative techniques such as homograft, stentless valves and pericardial valved tubes are not always suitable and require extensive experience for satisfactory results [2]. Homemade bioprosthetic valved conduits for root replacement are made through a simple and reproducible technique with good results [3].

Nevertheless, bioprosthesis degeneration is a well-known problem and could lead to a high risk of reoperation in young patients [4].

We introduced a modification of the original technique to simplify the reoperation in case of bioprosthesis degeneration.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
After a median sternotomy, cardiopulmonary by-pass is established cannulating the distal ascending aorta or aortic arch and right atrium. Normothermic antegrade/retrograde blood cardioplegia is infused following aortic cross-clamping and is repeated every 20 min in the retrograde fashion. The redundant aortic wall is excised and the coronary buttons prepared. A careful sizing of aortic annulus is obtained with a standard valvular-sizer. Pericardial valves and Valsalva Tube Graft (Gelweave, Valsalva-prosthesis, Vascutek, Terumo) were used in all patients. Usually we chose a tube graft two sizes larger than the bioprosthesis for better anatomic relations.

The composite valvular tube is made through the following steps: first the Valsalva-graft is everted by pulling its proximal end upward and inward (Fig. 1a). The bioprosthesis is sutured on the free margin of the everted graft with a running 4-0 polypropylene suture (Fig. 1b).

View larger version (131K): [in this window] [in a new window]   Fig. 1. (a) The Valsalva Tube Graft (Gelweave, Valsalva-prosthesis, Vascutek, Terumo) is everted outward. (b) The bioprosthesis is sutured on the free margin of the everted graft with a running 4-0 polypropylene suture. (c and d) Once the anastomosis is completed the homemade biologic valved tube is everted in the normal position.

View larger version (129K): [in this window] [in a new window]   Fig. 2. (a) The bioprosthesis and at least 2 mm of the Valsalva graft are left in the internal side of the tube creating a double sewing ring, the first ring (white arrow) is used to sew the graft to the aortic annulus, the second ring (black arrow) is used to fix the biological valve to the vascular graft. In case of reoperation the degenerated biological valve could be removed by cutting the suture on the second ring. That could then be used to fix a new prosthesis. (b) The proximal anastomosis is performed by means of three separate running 3-0 polypropylene sutures between the aortic annulus and the new free edge (first ring) of the Valsalva-prosthesis (white arrow).

The mean age was 63.2 years (range 43–77 years); 10 were male. The mean aortic cross-clamp time was 68 ± 10 min, the mean cardiopulmonary time was 79 ± 12 min. No rethoracotomy for bleeding was required. The hospital mortality was 0% and the postoperative period was uneventful in all patients. To date no patients had reoperations and they are in good clinical condition.

	3. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
In the 1968 Bentall and DeBono [1] described the technique for replacement of aortic root with a valved conduit in patients with aortic root pathologies. The Bentall operation is performed frequently with commercially available industry-made mechanical valved conduits in which lifetime anticoagulation is mandatory. Recently many techniques of intraoperative homemade biological valved conduit have been introduced for those patients unable, unwilling or too unreliable to maintain adequate anticoagulation [3,5].

Biological Bentall technique is justified by the aging of the population and by early diagnosis of aortic root pathologies in young people.

Even more frequently young patients want biological prosthesis because of life style, wish of pregnancy and other reasons, in spite of the reoperation risk. The life expectancy of the present cohort of patients exceeds the demonstrated durability of bioprosthesis. In the years to come reoperation for biological valve degeneration could always be more frequent.

During reoperation it is usually very hard to change the bioprosthesis alone and therefore a new complete root replacement is required. Reoperation is technically demanding because of the fragility of the aortic annulus, difficult and dangerous isolation and mobilization of coronary ostia [6].

Our technique has been studied to simplify the replacement of degenerated bioprosthesis without replacing the vascular graft.

The degenerated bioprosthesis is removed cutting the suture between the vascular graft and the valvular sewing ring. In our experience this technique is simple and reproducible, the Valsalva-tube reduces the tension on coronary button anastomosis and allows us a limited coronary arteries mobilization and better flow dynamics [7]. With this technique the size of the valve could be chosen independent of the annulus diameter.

This independent selection of graft and valve size eliminates the potential for valve-to-graft mismatch. Moreover, this double folded sewing skirt could be useful to secure anastomosis of the aortic root even in case of small or calcified aortic annulus with good hemostatic properties. This aspect could be useful also in a Bentall operation with a mechanical valve.

With this approach the prosthesis selection can be tailored to the individual anatomic and functional profile and when necessary reoperation could be accomplished as an isolated procedure respecting the previously reconstructed aortic root.

Nevertheless, we had a limited experience and to date neither of our patients required reoperation for valve degeneration.

However, we showed that this modification did not increase the operative risk of a standard Bentall operation [3,5]. Further investigation is required due to the small cohort of patients and the short follow-up time.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 

1. Bentall H, DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
2. Sommerville J, Ross D. Homograft replacement of aortic root with reimplantation of coronary arteries. Br Heart J 1982;47:473-482.[Abstract/Free Full Text]
3. Galla JD, Lansman SL, Spielvogel D, Minanov OP, Ergin MA, Bodian CA, Griepp RB. Bioprosthetic valved conduit aortic root reconstruction: the Mount Sinai experience. Ann Thorac Surg 2002;74:1769-1772.[CrossRef]
4. Plume SK, Sanders J. The Carpentier-Edwards stented supraannular pericardial aortic valve prosthesis: clinical durability and hemodynamic performance. Curr Opin Cardiol 2002;12:183-187.
5. Michielon G, Salvador L, Da Col U, Valfrè C. Modified button-Bentall operation for aortic root replacement: the miniskirt technique. Ann Thorac Surg 2001;72:1059-1064.[CrossRef]
6. Schepens MA, Dossche KM, Morshuis WJ. Reoperations on the ascending aorta and artic root: pitfalls and results in 134 patients. Ann Thorac Surg 1999;68(5):1676-1680.[Abstract/Free Full Text]
7. De Paulis R, De Matteis GM, Nardi P, Scaff R, Buratta M, Chiariello L. Opening and closing characteristics of the aortic valve after valve sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487-494.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alberto Albertini Claudio Zussa Mauro Lamarra Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Albertini, A. Articles by Lamarra, M. Search for Related Content PubMed PubMed Citation Articles by Albertini, A. Articles by Lamarra, M. Related Collections Cardiac - other Great vessels Valve disease