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Bentall Procedure: Everything You Need to Know

A Surgery to Repair the Aortic Root and Aortic Valve

How to Prepare

• Day of Surgery

The Bentall procedure is a type of serious open-heart surgery needed to repair the aortic root and the aortic valve, such as might be needed for an aortic aneurysm in this part of the aorta . The procedure is named for Hugh Bentall, who first performed and described it in 1968.  

Westend61 / Getty Images

What Is the Bentall Procedure?

The Bentall procedure is a type of open-heart surgery to replace the aortic valve and aortic root (and sometimes more of the ascending aorta).   It might be formed as a pre-planned surgery or under emergency circumstances. To understand the Bentall procedure, it’s helpful to understand a little about the anatomy of the heart and blood vessels.

The aorta is the large blood vessel that carries oxygenated blood from the heart. Blood vessels leaving the aorta provide oxygenated blood to the whole body.

The aortic valve , which lies just where the aorta connects with the heart, prevents blood from flowing backward into the heart.

The aortic “root” is a term used for the very beginning of the aorta. You also might hear the term “ascending aorta,” which refers to a slightly longer portion of the aorta (before any blood vessels have branched off it), including the root itself.

Sometimes the aortic root can develop an aneurysm, the general term for a blood vessel that balloons out and becomes larger than normal in size. When that happens, it can affect how well the valve functions as well.

Contraindications

A person might not be able to have a Bentall procedure if they aren’t medically stable enough to have a major heart surgery (e.g., their blood pressure is too low).

Potential Risks

Like all forms of open-heart surgery, the Bentall procedure has inherent risks. It is a serious intervention, and unfortunately not everyone survives. One study cited the risk of death within 30 days of hospitalization at around 5%.

The risks of possible complications include the following:

• Abnormal heart rhythm
• Low cardiac output
• Heart attack
• Infection (e.g., sepsis , pneumonia, or surgical wound infection)
• Internal bleeding (which might necessitate surgical repair)
• Sudden kidney failure (which might be temporary or permanent)
• Prolonged need for mechanical ventilation
• New aortic aneurysm or dissection of the aorta

You may have a greater risk of certain of these complications if you have other medical conditions (like diabetes) or if your existing heart condition is particularly severe. Fortunately, the risks of some of these complications have decreased since the procedure was first performed, due to improved surgical techniques.

Purpose of the Bentall Procedure

The problems with the aorta and aortic valve can happen due to a variety of medical problems.

One of the most common is Marfan syndrome , a genetic condition that causes problems with a person’s connective tissue, including some of the tissue in the aortic root and valve. This can cause the area not to form normally or to develop problems over time. In addition to other potential medical problems, a person with Marfan syndrome might have an aneurysm form in their ascending aorta.  

However, sometimes people develop problems in these areas for other reasons. Other possible underlying causes include:

• Other hereditary syndromes that affect the heart
• Physical trauma
• Infection (like from a bacterial infection)
• Autoimmune disease (like from Takayasu arteritis )
• Congenital heart problems
• General degeneration (caused by high blood pressure, atherosclerosis, and smoking)  

In any case, these problems need to be surgically repaired if the aneurysm is large enough. The most important consideration is the risk that the aneurysm will start to dissect . That means that the layers of the blood vessel will start to separate.

This can cause the artery to burst, leading to a life-threatening emergency. To prevent this, some intervention, such as the Bentall procedure, is necessary. The Bentall procedure might also be needed as an emergency surgery if an aneurysm has already ruptured.

To evaluate whether a Bentall (or similar) procedure is needed, you’ll need some medical imaging. Depending on the context, this might mean one or more of the following:

• Chest X-ray
• Transthoracic echocardiography
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI): Cardiac MRI and/or MRI angiography

Through these imaging techniques, your healthcare providers can check out your specific anatomy and evaluate whether the Bentall procedure is the best way for you to go.

Choosing Surgical or Medical Management

Not everyone with an aortic root aneurysm will need surgical repair (such as a Bentall procedure). It’s important to weigh the risks of surgery with the risks of not having the surgery.

If the aneurysm is small, it’s unlikely to dissect. If that’s the case, your healthcare provider might recommend waiting on surgery and monitoring you with imaging techniques, at least initially.

For people who don’t have an underlying medical condition that caused their problem (other than high blood pressure), it’s currently recommended to have preventative surgery when the aorta diameter is 5.5 centimeters (cm) or if it seems to be growing quickly.

However, your healthcare provider might recommend the surgery even if your aorta isn’t quite that big if you have a condition like Marfan syndrome.

If you decide not to have surgery (at least for the present), your healthcare provider may recommend treatment with medications instead, especially those to lower your blood pressure. For example, you might need to start taking a beta blocker (like propranolol) or an ACE-inhibitor (like captopril).

Other people may need to take a statin drug (like Lipitor) if they have atherosclerosis that may have contributed to their condition. However, none of these medications fixes the underlying problem.

Clearance for Surgery

Before your surgery is planned, your healthcare provider will want to make sure you are in good condition for it. This will include a general medical history and medical exam. It may also include some tests like EKG, basic blood work like a complete blood count (CBC) , and others as needed.

If you experience serious symptoms, like sudden chest pain or shortness of breath, call 911 right away. This may be a sign that your aneurysm has started to dissect. Seek immediate medical attention for this potentially life-threatening emergency.

Picking Your Surgery Type

Depending on the exact situation, you might have surgical options other than a Bentall procedure. Sometimes, healthcare providers may be able to repair the aortic root without needing to replace the aortic valve through a newer surgical technique. This is sometimes called a “valve sparing” procedure.

In this case, the procedure performed is not technically a Bentall procedure. This procedure may have a reduced risk of complications compared to a Bentall, such as the risk of endocarditis .

Another advantage over some types of Bentall procedures is that a valve sparing surgery does not require long-term treatment with anticoagulant medications. Some healthcare providers now recommend such a procedure over a Bentall in situations in which it is medically possible. But it’s not always a viable option.

Bentall Procedure Valve Selection

When planning to have a Bentall procedure, one of the key choices to make is whether to have a mechanical valve replacement or a valve replacement performed with a synthetic, biologic material.

The advantage of choosing a mechanical valve is that they are very durable and last for many years. However, people who have mechanical valves need to be on life-long anticoagulation treatment (such as via warfarin ).

This helps ensure that you don’t get a blood clot that forms on the replacement valve. However, these medications come with risks (particularly increased risk of bleeding) and a greater need for monitoring for the rest of your life.

On the other hand, if you have a synthetic biological valve replacement, you won’t need to take anticoagulation medications. A disadvantage is that these valves don’t last as long as mechanical valves, so you may be more likely to need a follow-up surgery.

Working with your healthcare provider, you can make the best surgical choice for you based on your clinical situation, your age, and your lifestyle preferences.

The procedure will be performed in the surgical or cardiac wing of your chosen hospital.

What to Wear

It doesn’t matter what you wear when you come to the hospital. You may want to leave any valuables, such as rings, at home.

Before you go to surgery, you’ll need to change into a hospital gown. You’ll need to remove any jewelry, glasses or contacts, hearing aids, or dentures.

Food and Drink

Like other surgeries, you’ll need to not eat or drink ahead of time, in order to reduce the risk of complications. Typically, you’ll be asked not to eat or drink anything after midnight the night before your planned surgery.

Medications

Before the surgery, make sure your healthcare provider knows about all the medications you are taking, including over-the-counter ones. Particularly make sure to ask about medications that might affect blood clotting, such as aspirin or anticoagulant medications like warfarin.

Your healthcare provider might want you to stop taking them for a time before the surgery, but don’t do this without checking in first. It’s also a good idea to bring a printed list of your medications on the day of your surgery itself.

What to Bring

Because you will need to be in the hospital for several days, bring whatever you need to help you feel comfortable (e.g., slippers, a robe). It’s also a good idea to bring your insurance information.

Pre-Op Lifestyle Changes

If you are a smoker, it’s a good idea to quit before your surgery. Even quitting the day before can help you reduce your risk of complications, but longer is better.  

What to Expect on the Day of Surgery

Before the procedure.

You’ll be expected to arrive well ahead of your surgery. You’ll be evaluated by one or more health professionals who will make sure that you are in good health to move forward with the procedure.  

For example, you’ll be asked about any new symptoms, like fever. You’ll also probably be asked again about other parts of your medical history, like your allergies and your current medications. If anything is unusual with your health, this is the chance to share that information.

Someone will also check your vital signs, like your blood pressure, and you’ll have a basic medical exam performed. Someone may also shave the area around your chest.

During the Surgery

The operation should take around five hours, but it might be more. (This doesn’t include the preparatory period or the time in surgical recovery). A whole surgical team will be available to monitor your vital signs and help get you through the surgery successfully.

Eventually you’ll be taken from a preoperative area into the surgical room itself. You’ll receive general anesthesia during the operation, so you won’t feel any pain, and you won’t remember anything about it afterward.

Someone will insert a catheter to collect your urine during the operation. You'll also have a special tube placed down your airway, which will be connected to a ventilator.

When everything is ready, the surgeon will make a cut in your chest, through the breastbone, to access the aortic valve and the aorta.

During the part of the surgery on the heart and related structures, you will be connected to a heart-lung bypass machine . This machine can do the work that your heart and lungs would normally do. This allows the surgeon to stop your heart temporarily while working on the aorta and its valve.

The surgeon will clamp the aorta and remove the damaged section of the aorta and valve. Then the surgeon will replace that part of the aorta with a prosthetic tube (called a graft). Inside the graft is an artificial aortic valve (either of the mechanical type or one made of biological tissue).

The surgeon will surgically connect one end of the graft to your remaining, normal aorta. The other end containing the valve is also sewn into the heart. The surgeon will also need to sew the coronary arteries (that bring blood to the heart itself), to make sure they receive adequate blood flow after the operation.

After everything is in place, the clamp can be removed. You’ll come off the heart-lung machine and your heartbeat will be restarted, as the blood flows through the artificial valve and graft and out into the rest of your body.

Depending on the exact clinical situation, the Bentall procedure may not be the only procedure necessary for your heart. For example, you might need repair or replacement of a different heart valve, or you might need some other sort of heart intervention. If so, these can take place either right before or right after the Bentall procedure.

Your sternum may be closed with wires. The surgeon will also surgically close the incision across your chest. 

The exact details of the procedure will vary based on the specific version of the Bentall technique your surgeon is choosing. Don’t feel like you have to get overly involved in the details, but don’t hesitate to bring up any questions that you have.

After the Surgery

Someone will take you to a surgical recovery area, where you’ll be carefully monitored. After a while, you’ll wake up, but you may be groggy for a while.

At first, you may be attached to a ventilator via an endotracheal tube . You’ll have one or more tubes attached to drain excess fluid and air from your chest. You might also have a catheter in the artery in your wrist (an arterial line) so your medical team can better monitor your condition.  

If everything seems to be going well, you’ll be moved to the room where you’ll stay overnight, probably in the intensive care unit. Here they can carefully monitor you and make sure you aren’t having any immediate complications from your surgery, such as blood clot in your leg or lungs.

If you need to, you can have medication for the pain following the surgery. Usually, people can eat and drink again the day following surgery. After a day or so in the intensive care unit, you will probably be able to move to a general medical floor.

You’ll need to stay in the hospital for several days until you are well enough to go home. During this time, people will regularly be checking on your incision to make sure it is healing properly.

They’ll also be checking to see that you are able to pass stool without straining (as extra pressure might put stress on your wound). The urine catheter and chest tube are able to be removed within a couple of days.  

As soon as you can manage it, you’ll want to try moving around again. This will reduce your chance of complications, like forming a blood clot.

Before you leave, you’ll receive instructions on follow-up care, such as continued care for your healing chest incision . You may still need to keep it away from water until your wound fully heals.

You’ll also receive instructions on when you will see your healthcare provider again (such as a week or so later in an outpatient clinic). Someone will need to be able to drive you home. You won’t be able to do that yourself for a few weeks or so, or maybe more.

Call 911 right away for signs of potentially serious complications like sudden chest pain. Call your healthcare provider promptly if you have other new symptoms, like fever. These might indicate a complication that needs medical attention.

Coping With Recovery

Even when you are ready to leave the hospital, you may still fatigue easily. You need to give yourself time to recover from this major surgery.

Some people will benefit from cardiac rehabilitation to help get them moving again. Your healthcare provider is the best person to tell you when you are ready to return to your normal activities, but it may take you a several months to fully recover.

Long-Term Care

If you had a problem with your aorta and valve due to another condition, do what you can to decrease your risk of a future aneurysm . For example, if you have atherosclerosis and/or high blood pressure, taking your medications as prescribed may help you reduce your risk.

Quitting smoking may also help you decrease your risk of a future aneurysm and of certain complications.  

Additionally, people who receive a mechanical valve as part of their Bentall procedure will need to receive life-long anticoagulation . As part of this, you may need to receive regular blood tests to make sure your blood is clotting the right amount.  

Possible Future Surgeries

Some people who receive the Bentall procedure do very well and never need repeat surgery. However, some people eventually need to have another surgery.

This might be more likely to happen if you have a disease like Marfan syndrome, and the underlying problem causes another aneurysm to develop. In this case, you might need some kind of surgical repair on your aorta.  

A Word From Verywell

There’s a lot to consider if you have a problem with your aorta and aortic valve that might benefit from the Bentall procedure. Surgery might or might not be the best option for you, depending on your situation.

Beyond that, you may have choices about your surgical options, including whether to have a Bentall procedure specifically and whether you want to receive a mechanical valve. Discuss all the pros and cons with your healthcare provider to help make the best choice for you.

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Joo HC, Chang BC, Youn YN, Yoo KJ, Lee S. Clinical experience with the Bentall procedure: 28 years . Yonsei Med J . 2012;53(5):915-923. doi:10.3349/ymj.2012.53.5.915

Mookhoek A, Korteland NM, Arabkhani B, et al. Bentall procedure: a systematic review and meta-analysis . Ann Thorac Surg . 2016 May;101(5):1684-9. doi:10.1016/j.athoracsur.2015.10.090

Pepe G, Giusti B, Sticchi E, Abbate R, Gensini GF, Nistri S. Marfan syndrome: current perspectives .  Appl Clin Genet . 2016;9:55-65. doi:10.2147/TACG.S96233

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National Heart, Lung, and Blood Institute. Heart surgery . 

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Applegate PM, Boyd WD, Applegate RL, Liu H. Is it the time to reconsider the choice of valves for cardiac surgery: mechanical or bioprosthetic? .  J Biomed Res . 2017;31(5):373-376. doi:10.7555/JBR.31.20170027

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By Ruth Jessen Hickman, MD Ruth Jessen Hickman, MD, is a freelance medical and health writer and published book author.

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• Open access
• Published: 19 December 2022

Early and midterm outcomes of a bentall operation using an all-biological valved BioConduit™

• Roxana Botea 1 , 2 ,
• Yoan Lavie-Badie 2 ,
• Alexandru Goicea 1 , 3 ,
• Jean Porterie 1 &
• Bertrand Marcheix 1  

Journal of Cardiothoracic Surgery volume  17 , Article number:  325 ( 2022 ) Cite this article

1122 Accesses

Metrics details

To analyze the midterm results of aortic root replacement using the valved, all biological, No React®, BioConduit™.

From 2017 to 2020, we prospectively followed 91 consecutive patients who underwent a Bentall procedure with a BioConduit™ valved graft in our institution. The primary outcomes were aortic bioprosthetic valve dysfunction and mortality according to Valve Academic Research Consortium 3 (VARC3).

Mean age was 70 ± 10 years and 67 patients (74%) were men. Ascending aortic aneurysm (72%), aortic valve regurgitation (51%) or stenosis (20%) and acute endocarditis (14%) were the main indications for surgery. Seventy-four patients (81.3%) were followed up at 1 year. The perioperative mortality was 8% (n = 8), the early, 1 year, mortality was 2% (n = 2) and the midterm mortality, at 4 years of follow up, was 4% (n = 3). Ten patients fulfilled the criteria for hemodynamic valve deterioration at 1 year (13%) and 14 for a bioprosthetic valve failure during the entire follow-up (17%).

Conclusions

We are reporting early and midterm results of Bentall procedures with the all-biological, valved, No-React® BioConduit™. To our knowledge, this is the first study reporting an early and midterm unexpectedly high rate of non-structural prosthetic hemodynamic deterioration. The rate of endocarditis and atrioventricular disconnections remain similar to previous studies.

Peer Review reports

The Bentall procedure is the gold standard therapy in patients with either ascending aorta or aortic root aneurysm combined with aortic valve disease precluding a valve sparing procedure. [ 1 ]. The original technique described by Bentall and De Bono using a composite mechanical valved graft benefited from iterative refinements in order to overcome specific surgical drawbacks [ 2 ]. Nowadays, either preassembled or self-assembled conduits, associating tubular straight or Valsalva graft and biological or mechanical valve, are widely used [ 3 , 4 ]. As an alternative, a fully xenobiological stentless valved conduit, the Shelhigh NR-2000, was introduced in the late 1990’s and thereafter withdrawn from the market. Recently, a totally biological stentless conduits have been reintroduced in a modified version, using a porcine aortic valve and a bovine pericardial tube (BioIntegral™, BioValsalva™). The goal of our study was to investigate the early and midterm results of the Bentall procedure using BioIntegral™ BioConduit™ in our single-center experience.

Study design

It was a prospective observational study, without control-group, carried out from 2017 to 2020 in our tertiary centre.

Study population

All consecutive patients undergoing a Bentall procedure with the BioIntegral™ Surgical BioConduit™ No-React® in our institution (n = 91) were prospectively included during the study period. All patient data were collected from hospitals’ medical records. Cohort patients underwent an aortic root replacement with an all-biological graft in cases of complex endocarditis or redo surgeries, cases of patients who were not candidates for an autograft procedure but a mechanical graft was not indicated and in elderly patients with degenerative aortic root disease.

The study is conformed to the principles outlined in the Declaration of Helsinki. According to French law on ethics, patients were informed that their codified data would be used for the study. The patient also provided informed written consent for the publication of the study data. The Institutional Review Board of the Rangueil University Hospital of Toulouse, France, approved the study protocol and the publication of data (number RnlPH 2022-50) on the 7th of April 2022.

Surgical data

All interventions were performed by four senior surgeons. All patients were operated through median sternotomy. Standard cardiopulmonary bypass, aortic cross-clamp and anterograde and retrograde cold blood potassium-enriched cardioplegia were used in all patients. When an aortic arch replacement was performed, moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion through the right axillary artery were associated. After aortic cross-clamping, the aortic valve, the aortic root and the ascending aorta were excised, followed by aortic annulus decalcification when required. The coronary ostia were isolated with their buttons. After sizing of the aortic annulus, the prosthesis was chosen, with a trend in oversizing. The all-biological stentless valved bioconduit is designed to offer similar hemodynamics as the native aortic valve and theoretically aimed to insure a larger post-operative effective orifice area (EOA). The conduits’ No-React® treatment aims to reduce the grafts’ related infections and calcifications as well as to prevent remodeling and graft aneurysmal dilatation [ 5 , 6 , 7 ]. As the traditional glutaraldehyde preserved biological valves tend to calcify, the No-React® detoxification process promises to eliminate residual glutaraldehyde and to ensure stable tissue cross-linking, resulting in less or no calcification or tissue deterioration in the animal model [ 5 , 6 ]. A variety of BioConduit™ sizes between 21 to 29 mm were implanted. The trend of oversizing refers to choosing a conduit one-size oversized following the manufacturer’s recommendations, to achieve greater effective surface areas, avoiding mismatch [ 7 ]. Depending on operator preferences, two types of implantation techniques were used, either multiple single, interrupted, non-everting, reinforced U-stiches to implant the composite graft in supra-annular position (n = 33, 36%) or everting stitches to implant the prosthesis in intra-annular position (n = 58, 64%). Then, 2 holes were made in the tubular graft and both coronary ostia were reimplanted by running sutures (Prolene 6–0). Fibrin glue was used in most cases to reinforce sutures.

Imaging protocol

A post-operative transthoracic echocardiographic (TTE) assessment was performed before hospital discharge: 2D TTE standard views were obtained using a standard ultrasound system using a 1–5 MHz probe (VIVID S70, GE Healthcare). A new TTE assessment was conducted at 1 year, using the same system. EOA was calculated by the continuity equation method. Aortic annulus diameter was measured at mid-systole, from the parasternal long-axis view, at the level of the prosthetic annulus, in a zoomed mode, from inner-edge to inner-edge. The velocity–time integral of blood flow was measured in the left ventricular outflow track by pulsed doppler. Mean transaortic gradient and maximal velocity were evaluated by transprosthetic continuous wave doppler. The doppler velocity index was calculated as the ratio of the proximal peak flow velocity in the LVOT to the transprothetic peak flow velocity. All examinations were interpreted blindly on a dedicated workstation (EchoPac 204 GE Healthcare) by two operators. In addition, during the follow-up, in case of bioprosthetic valve failure (BVF), a TEE and a cardiac CT were performed.

Study outcomes

The endpoints used were those proposed by the Valve Academic Research Consortium 3 (VARC3).

Mortality [ 8 ]

Periprocedural mortality was defined as all-cause mortality occurring ≤ 30 days after the index procedure or occurring > 30 days but during the index hospitalization.

Early mortality was defined as death occurring > 30 days but ≤ 1 year after the index hospitalization.

Midterm mortality was defined as death occurring > 1 year after the index hospitalization but ≤ 4 years, at end of follow up.

Aortic bioprosthetic valve dysfunction (BVD)

In terms of etiology, BVDs were defined as structural valve deterioration (SVD), nonstructural valve dysfunction (NSVD), thrombosis or endocarditis. SVD was reported as intrinsic permanent changes of the prosthetic valve [ 9 ]. NSVD was reported as any abnormality not intrinsic to the bioprosthesis, resulting in its malfunction (e.g. pannus, prosthesis-patient mismatch) [ 9 ].

Hemodynamic valve performance assessment was protocolized at 1 year of the index procedure. Moderate hemodynamic valvular deterioration (HVD) was defined as an increase in the transaortic mean gradient of \(\ge\) 10 mmHg resulting in a mean gradient of \(\ge\) 20 mmHg, with concomitant decrease in the EOA \(\ge\) 0.3 cm 2 and decrease in doppler velocity index \(\ge\) 0.1 compared to the post-operative assessment. Severe HVD was defined as an increase in the mean gradient of \(\ge\) 20 mmHg resulting in a mean gradient of \(\ge\) 30 mmHg, with concomitant decrease in the EOA \(\ge\) 0.6 cm 2 and decrease in doppler velocity index \(\ge\) 0.2 [ 9 ].

During the follow-up, the occurrence of a BVF was considered as an endpoint. Finally, BVF was defined by the occurrence of BVD associated with clinically expressive criteria (heart failure symptoms, fever, angina, ischemic event), irreversible severe HVD, aortic valve reoperation or re-intervention or valve-related death [ 9 ].

Statistical analysis

Continuous variables were expressed as means ± standard deviation or as medians with interquartile ranges (IQR) when not normally distributed. Nominal variables were expressed as numbers and percentages. The association between the mean values of continuous variables was assessed using the Mann–Whitney rank sum test. Nominal variables were investigated by the χ 2 test or the Fisher exact test when appropriate. The software XLSTATS v2019.1 (Addinsoft, Paris, FR) was used for statistical analysis.

This study included 91 patients, mostly men (74%) with a mean age at intervention of 70 ± 10 years. Preoperative patient’s characteristics are reported in Table 1 . Most patients had an ascending aortic aneurysm (n = 65, 72%). There were 22 cases of redo procedures (24%). Sixteen procedures were performed on an emergency basis (18%), including 10 cases of type A acute aortic dissection (11%), 12 cases of severe prosthetic endocarditis (13%) and 1 complex of native aorto-mitral endocarditis. Forty-four patients underwent combined interventions (48%): coronary artery bypass graft in 22 cases (24%), mitral valve repair or replacement in 5 (6%) and aortic arch or hemiarch replacement in 14 (15.3%) cases.

Among the 83 patients discharged from hospital, 9 were lost to follow-up (10%). Median follow-up was 4 years.

The periprocedural mortality rate was 8% (n = 8). Among them, 3 patients with a pre-operative severe left ventricular dysfunction died shortly after the procedure from low cardiac output and multiorgan failure syndrome, 2 patients operated for complicated infective endocarditis on previous Bentall prosthesis died in the first 24 h from refractory septic vasoplegic syndrome, 2 patients operated for acute type A aortic dissection died either from massive hemorrhagic stroke or acute right ventricular failure in the first week after surgery and 1 patient experienced acute respiratory distress syndrome.

Early mortality rate was 2%. Among the 83 patients discharged from hospital, 2 died in the first year, both of them experiencing graft proximal anastomosis partial detachment at 9 and 10 months, respectively. Both were reoperated, but died from hemorrhagic stroke or massive intraoperative bleeding, respectively.

Midterm mortality rate was 4% (3 patients). One 62 years-old male, who had already undergone two Bentall procedures presented a recurrent bacterial graft endocarditis at 18 months after discharge. He was referred to surgery and died in the operating room from uncontrolled bleeding. One 83 years-old patient died from respiratory distress related to a severe form of Covid-19 pneumonia. The third, 72 years-old male died from metastatic pulmonary adenocarcinoma.

Bioprosthetic valve dysfunction

Early results

Regarding the prosthetic hemodynamic features, despite normal postoperative hemodynamic profiles, without signs of obstruction, we observed a decrease in graft performance at 1 year, mainly in terms of EOA (1.3 ± 0.2 cm 2 vs 0.9 ± 0.4 cm 2 , p = 0.02 for 23 mm graft, 1.6 ± 0.4 cm 2 vs 1.2 ± 0.5 cm 2 , p = 0.01 for 25 mm graft, 1.9 ± 0.5 cm 2 vs 1.5 ± 0.5 cm 2 , p < 0.01 for 27 mm graft, 2.1 ± 0.6 cm 2 vs 1.6 ± 0.6 cm 2 , p = 0.17 for 29 mm graft) but also in terms of transaortic mean gradient and maximum velocity. [ 10 , 11 ].

At the 1-year follow-up, 10 patients fulfilled criteria for HVD (13%), 6 being moderate and 4 severe. The factors associated with HVD are presented in Table 2 . Preoperative characteristics were not associated with HVD. The implanted graft caliber was significantly associated with the occurrence of HVD at 1 year (8 (80%) vs. 21 (33%), p  = 0.01 for 23- or 25-mm graft), especially in the smallest sizes.

However, the patients who secondarily developed HVD had similar hemodynamic parameters as the rest of the cohort at the pre-discharge postoperative exam.

There was 1 case (1.3%) of early graft endocarditis with negative blood cultures, diagnosed at 8 months after surgery. We treated it medically.

We noted three cases (4.1%) of partial proximal anastomosis disruption: two cases with total atrio-ventricular disruption with large false aneurysms at the level of the proximal anastomosis at 9 months and respectively at 10 months after the initial surgery. We did not find any argument in favor of an infective endocarditis. Moreover, one patient’s initial surgery was in an elective setting, for a degenerative aortic aneurysm. The third patient had a similar aortic root disruption, but it appeared 4 months after a Bentall intervention for a complex aortic and mitral endocarditis with fragile tissues.

Midterm results

Five patients experienced infective endocarditis (6.8%) at a median of 1 year and 4 months. One patient was treated surgically and the other 5, medically.

There weren’t observed any more cases of hemodynamic dysfunction or AV disruptions until follow up was closed.

Regarding early and midterm results, we observed a total of 14 patients presenting a BVF during follow-up (17%). A re-intervention was performed in 8 cases (10%). Three patients had a valve-in-valve TAVR for severe HVD. Five patients had open redo surgery: three cases of partial proximal anastomosis detachment, one case of graft endocarditis with valvular involvement and one severe HVD. Among them, 3 patients died related to the procedure.

Regarding etiologies of BVF, 6 patients experienced infective endocarditis (8%), 3 patients had partial proximal anastomosis detachment (4%) and the other 4 patients had severe irreversible HVD (5.5%). All patients with endocarditis underwent TTE and TEE which were abnormal in two cases, highlighting valve involvement (aortic vegetations (n = 2), aortomitral abscess (n = 1) and pseudoaneurysm (n = 1)). Endocarditis patients also underwent a CT scan which showed in all cases a proximal collection around the biological graft with peripheral contrast diffusion, without signs of a pseudoaneurysm. PET combined with CT (PET/CT) was also performed in four cases, showing an abnormal intense uptake on the graft collection and/or the valvular prosthesis. Regarding the pathogens involved, there were 2 cases of staphylococcus involvement (aureus and epidermidis), 1 with Enterobacter Aerogenes, 1 with E. coli, another case a streptococcus oralis infection and lastly, 1 with negative blood cultures.

For all patients with HVD, thrombosis was ruled out by CT, and endocarditis by Duke criteria. SVD was eliminated by TEE and CT. Of note, none of these patients had regurgitation. Regarding NSVD, a patients-prosthesis mismatch did not appear to be involved, as postoperative indexed EOA was not associated with the occurrence of HVD at 1 year. Finally, for all patients with HVD, imaging found a 3–4 mm, circumferential, hyperechogenic ring, located at the level of the prosthetic aortic annulus and at the graft’s proximal anastomosis towards its’ ventricular side, near the pledgets. In these patients, on CT and TEE, there was no structural prosthetic abnormality (neither fibrosis, calcification, leaflet tear and wear, hypo-attenuated leaflet thickening nor thrombosis). Moreover, we have randomly reviewed patients’ echocardiographic exams concluding that the circumferential structure is a common finding in patients being implanted with this type of biological graft. Indeed, 29 patients had a reduction of their aortic annulus size at 1 year (39%). We identified this annular structure in the per-operatory setting, during the reintervention for a failing bioprosthesis (Fig.  1 ).

A Transesophageal echocardiography, deep transgastric view, annular hyperechogenic structure (yellow arrow); LVOT—left ventricle outflow tract; B Intraoperative view with the annular diaphragmatic structure (black arrow) visualized after complete prosthetic dissection

This prospective study reports the midterm outcomes of 91 consecutive patients who underwent a Bentall procedure with the BioConduit™ No React® between 2017 and 2020, in our institution. Main results are as follows: 1) the hemodynamic performances at 1 year were unsatisfying, with an overall trend towards reduction in EOA and a significant rate of HVD, 2) despite the No-react® treatment of the conduit, graft endocarditis was not rare and 3) we observed some cases of early graft detachment at its proximal anastomosis with the aortic root.

Biological bioconduits, by avoiding stent and sewing cuff at the annular level, are intended to achieve more physiological flow pattern and thus superior hemodynamics [ 7 , 12 , 13 ]. However, our study identified a high rate of HVD and a general decrease in EOA at 1 year as being related to prosthesis of smaller calibers (23 and 25 mm) ( p  < 0.001) and renal insufficiency ( p  < 0.001) (Table 2 ). Even though we observed a general reduction in the annulus diameter, we think it had a more rapid obstructive impact in initially smaller calibers.

Regarding patients with HVD, our imaging protocol allowed us to rule out endocarditis, thrombosis or SVD in all cases. Our main observation explaining this phenomenon causing NSVD might be similar to a pannus formation. Firstly, we noticed a reduction in the aortic annulus diameter at 1 year (Fig.  2 ). In addition, we found a 3–4 mm, external circumferential, hyperechogenic, non-perfused ring, situated at the level of the prosthetic aortic annulus and at the graft’s proximal anastomosis near the pledgets. This structure was identified during our imaging protocol and confirmed in the perioperative setting (Fig.  1 ). We concluded that HVD was probably related to the external circumferential diaphragm that explained the shrinkage of the aortic diameter. Nevertheless, it is interesting to notice the rapid development of this “pannus-like” structure, in less than a year (Additional files 1 , 2 , 3 ). Concerning its potential cause, several hypotheses are put forward. It may be related to the surgical techniques as the structure was near the pledgets used for our surgical interrupted suture, reinforced with biological fibrin glue.

Transthoracic echocardiography, long axis parasternal view with same patient early post-operatory ( A ) and ( C ) and 1-year follow up exam ( B ) and ( D ), showing a shrinkage of the aortic annulus at 1 year (measured at the level of the yellow arrows), from 18 to 14 mm ( A ) and ( C ) together with a transaortic mean gradient and maximal velocity by Doppler continuous wave interrogation, from 2,4 m/sec and 12 mmHg ( B ) to 4,6 m/sec and 59 mmHg ( D )

As for the surgical implantation technique, we used either a multiple, single, interrupted, non-everting, pledged reinforced U-stiches to implant the composite graft in supra-annular position (n = 33, 36%) or everting stitches to implant the prosthesis in intra-annular position (n = 58, 64%). After univariate analysis, we found no correlation between the technique and the event of bioprosthetic valve dysfunction (Table 2 , p  = 0.47).

We can also consider the role of the immune system. The glutaraldehyde bioconduit treatment is meant to eliminate immunogenic proteins [ 14 ]. Nevertheless, multiple observational studies identified xenograft porcine components (extracellular matrix specific glycans, galactose-a-1,3-galactose and N-glycolylneuraminic acid) who trigger host antibody formation [ 15 , 16 , 17 , 18 , 19 ]. Sustaining the same immunogenic hypothesis, a group from Munich studied the effects of a pericardial porcine, No-React® patch and they found sterile abscess formation that was suspected to be an immunogenic reaction, a xenogeneic complement-mediated graft rejection [ 20 ]. The question of patient-prosthesis mismatch can be raised because the smallest sizes of prostheses seemed to be more sensitive to hemodynamic deterioration. We believe that this observation is not related to an initial mismatch but to the fact that a decrease in EOA logically has more impact on a small prosthesis than on a larger one.

In light of all of the above, we speculate an early inflammatory reaction could have been triggered by the biological conduit itself, favored by the use of biological glue or/and by the surgical technique (all patients were implanted using a multiple, single, interrupted, everting or non-everting suture with pledged reinforced U-stiches). Lastly, concerning the surgical technique, we note that other teams (Carrel et al., Stefanelli et al., Sahin et al., Kaya et al., Galinanes et al.) reported using as technique of conduit implantation either a running suture or an interrupted, nevertheless, they were not confronted with this problem [ 13 , 21 , 22 , 23 , 24 ].

Six patients were diagnosed with graft endocarditis. Diagnosis was made according to the modified Duke criteria and was often difficult, due to a combination of atypical clinical, biological, radiological and echocardiographic observations [ 25 ]. These features are not specific to this conduit and are usual after Bentall surgery. These results are surprising insofar as one of the advantages put forward in favor of these conduits is their expected low rate of reinfection.

In this regard, Galinanes et al. reported excellent late results (1 case of conduit infective endocarditis in 10 years) [ 13 ]. Siniawski et al., Musci et al. and Wendt et al. suggested the same reassuring results [ 26 , 27 , 31 ]. Recently, Stefanelli et al. also reported satisfactory results, with freedom from the BioConduit® graft infection of 95.7% at 5 and 15 years (CI 0.95) [ 22 ]. However, larger cohorts are still needed to confirm these results.

Previous studies reported a high number of aorto-ventricular disconnections especially related to the initial Shelhigh’s biological conduit [ 21 , 23 , 24 , 28 ]. The Shelhigh graft was a stentless, valved, No-React® biological conduit implanted mostly in the early 2000s. Due to unexpected conduit disconnections, in 2007, the United States FDA published a notification, the product being retried of the market [ 28 , 30 ]. Despite this drawback, in 2013, Musci et al. published reassuring results after 11 years of follow-up of 255 patients implanted with Shelhigh initial graft [ 30 ]. The Berlin group reported a low reinfection rate (0.78% early and 2.35% late reinfection) concluding that patients’ outcome was dependent of their surgical urgency. Afterwards, a new version of the graft, the BioIntegral Surgical, BioConduit™ was released on the market. Regarding its predecessor (the Shelhigh conduit), while some teams report relatively satisfactory early and late follow-up results (Galinanes et al., Musci et al.), other teams report some dreadful complications (Sahin et al., Kaya et al., Carrel et al., Reineke et al., Sadeque et al.) referring to the high rate of endocarditis and of atrio-ventricular disconnections with proximal false aneurysm formation [ 13 , 21 , 23 , 24 , 27 , 28 , 29 , 30 , 32 ]. In contrast, they report conduit hemodynamic dysfunction only in a few cases. Reineke et al. describes 8 cases (2.3%) with structural valve deterioration at late follow up. In contrast, Kaya et al. reports 3 cases (1.7%) with hemodynamic failure at early follow-up, without detailing. Concerning the BioConduit™, Stefanelli et at publishes satisfactory early and long-term results [ 22 ]. In our series, we report 10 cases (13%) presenting criteria for non-structural hemodynamic valve dysfunction at 1 year and 4 of them fulfilling criteria for failure, needing reintervention. This was an unexpected finding, as to our knowledge, such a high incidence of biological conduit hemodynamic dysfunction was never cited before.

There are several limitations of this study. This was a prospective but single-center, non-randomized study with lack of group control. Even though there were 91 patients included, the population analyzed was rather small and heterogenous, gathering elective as well as emergent cases. Being a single institution study, with 4 surgeons and 2 techniques, while representing a limitation, could contribute to reducing biases related to the use of multiple techniques.

This study reports the early and midterm results of the newest all-biological valved conduit. Even though it is designed to achieve superior hemodynamics by excluding the valvular stent, our study reveals an abnormally high rate of early prosthetic non-structural dysfunction and failure that appears to be mostly related to a multifactorial progressive shrinkage of the aortic annulus. Regarding graft infections, we observed that endocarditis is not rare, despite conduits all-biological structure. Lastly, there are still some cases of conduit proximal anastomotic detachments.

Availability of data and materials

The datasets and the materials used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Bioprosthetic valve failure

Effective orifice area

Hemodynamic valve deterioration

Nonstructural valve deterioration

Patient-prosthesis mismatch

Structural valve deterioration

Transcatheter aortic valve replacement

Transesophageal echocardiogram

Transthoracic echocardiogram

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The corresponding author (RB) and YL-B conceived and designed the analysis. AG collected data and conceived the tables. YL-B performed the statistical analysis. All authors discussed the results and contributed to the final manuscript. The corresponding author and JP wrote the paper. All authors read and approved the final manuscript.

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Additional file 1. Video 1 Transthoracic echocardiography, long axis parasternal view. Exam at 1-year follow up exam showing a diminished and hyperechogenic, with a pannus-like structure at the level of the aortic annulus.

Additional file 2.  Video 2 Transthoracic echocardiography, long axis parasternal view. Exam at 1-year follow up exam showing a diminished and hyperechogenic, with a pannus-like structure at the level of the aortic annulus.

Additional file 3. Video 3 Transthoracic echocardiography, long axis parasternal view. Exam at 1-year follow up exam showing a diminished and hyperechogenic, with a pannus-like structure at the level of the aortic annulus.

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Botea, R., Lavie-Badie, Y., Goicea, A. et al. Early and midterm outcomes of a bentall operation using an all-biological valved BioConduit™. J Cardiothorac Surg 17 , 325 (2022). https://doi.org/10.1186/s13019-022-02073-5

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Bentall procedure as a lifesaving surgery: A single center experience

Affiliations.

• 1 Department of Cardiac Surgery, Ibn Al-Bitar Specialized Center for Cardiac Surgery, Baghdad 10011, Iraq.
• 2 College of Medicine, University of Sulaimani, Sulaimani, Kurdistan 46000, Iraq.
• 3 Smart Research Center, Smart Health Tower, Sulaimani, Kurdistan 46000, Iraq.
• 4 Kscien Organization, Sulaimani, Kurdistan 46000, Iraq.
• 5 Department of Surgery, Mosul Cardiac Center, Mosul 41001, Iraq.
• 6 Sulaimani Center for Heart Disease, Sulaimani, Kurdistan 46000, Iraq.
• 7 Department of Surgery, Shar Hospital, Sulaimani, Kurdistan 46000, Iraq.
• PMID: 36733412
• PMCID: PMC9887084
• DOI: 10.3892/mi.2023.68

The Bentall procedure is a surgical technique used in the management of aortic root abnormalities with ascending aorta and aortic valve issues. The present study aimed to evaluate the outcomes of 18 patients treated with the Bentall procedure in a single center. The present study was a single-center retrospective case series conducted over a period of 3 years. The patients had either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction. The Bentall procedure was performed via standard median sternotomy. St. Jude Medical composite grafts with a valve were applied in all cases. A total number of 18 patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction were included in the study. The age of the participants ranged from 27-60 years. The ratio of males to females was 16:2 (males, 88.8%). The symptoms developed 3-4 days prior to hospital admission. Chest pain was the most common presenting symptom (n=10, 55.5%). Hypertension was the most common risk factor (n=12, 66.6%). In total, 14 cases underwent emergency surgery (77.7%). The emergency surgery was performed in 9 patients within 24 h of arrival owing to the association of aortic root dissection with tamponade. For the other cases, the surgery was performed within 2 and 7 days (n=5, 27.7% and n=4, 22.2%) respectively. Early post-operative complications occurred in 5 patients (27.7%). On the whole, as demonstrated herein, the modifications of the Bentall procedure have a notable impact on decreasing the overall mortality rates. Raising the awareness of clinicians and the general population as regards aortic dissection may aid in the early referral of patients to specialized centers and may thus decrease the overall mortality rate.

Keywords: aortic root dilatation; aortic root dissection; bicuspid aortic valve; chest pain.

Copyright: © Al-Mudhaffar et al.

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Original research article, mini-invasive bentall procedure performed via a right anterior thoracotomy approach with a costochondral cartilage sparing.

• 1 Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
• 2 Shanghai Municipal Institute for Cardiovascular Diseases, Shanghai, China

Objectives: A right minithoracotomy approach with a sternal sparing technique is a minimally invasive option for surgeons performing aortic root surgery. This report presents our initial clinical results of the right minithoracotomy Bentall procedure.

Methods: Clinical data of 15 patients were retrospectively analyzed who underwent the minimally invasive Bentall procedure through the right anterior thoracotomy via the second intercostal incision without any costochondral cartilage invasion at our institution between October, 2019 and June, 2021. The operative time, length of intensive care unit stay and postoperative hospital stay, perioperative outcomes, and follow-up results were analyzed.

Results: The median aortic cross-clamping time was 95.0 (85.5–98.8) min. Three (21.4%) patients received blood transfusion. The median drainage volume in the first 24 h was 200.0 ml, with no redo for bleeding. The median duration of mechanical ventilation was 12.5 (11.0–25.0) h, and median length of intensive care unit stay was 1.5 (1.0–3.0) day. All patients discharged 5.8 ± 1.2 days following surgery, with no dead patients found. At 6 months following surgery, all patients survived with an improved New York Heart Association (NYHA) functional class.

Conclusion: The right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. This approach should be considered as an option in carefully selected patients requiring aortic root replacement.

Introduction

As technology advances and surgeon experience increases, increasing patients undergo mini-invasive cardiac surgery, and the range of minimally invasive cardiac surgery continues to broaden. The most common surgical approach to aortic root replacement is a full median sternotomy ( 1 , 2 ). An increasing number of surgeons are employing a ministernotomy approach, including upper hemi-sternotomy and other partial minimal sternal variations, to complete this procedure ( 3 – 5 ). The ministernotomy approach confers advantages with respect to bleeding, respiratory recovery time, and risk of mediastinitis when compared with full sternotomy approach in selected patients ( 3 – 5 ).

A right anterior minithoracotomy approach for minimally invasive aortic valve replacement (AVR) is a well-established surgical procedure. It has several advantages over AVR through sternotomy in terms of decreased blood loss, shortened length of hospital stay, decreased pain, early recovery of pulmonary function, improved cosmesis, and a rapid return to daily activities ( 6 , 7 ). The success of the right minithoracotomy AVR may translate into favorable outcomes in selected patients undergoing the right minithoracotomy approach for aortic root surgery. Recently, a right minithoracotomy Bentall procedure which includes the utilization of video guidance and automated suturing technology has been described ( 8 ).

At our institution, the right anterior minithoracotomy approach has been the preferred minimally invasive technique used for isolated AVR. We have recently introduced the right minithoracotomy Bentall procedure with conventional instruments and suturing techniques. In this report, we presented our initial clinical results of right minithoracotomy Bentall procedure, and tried to evaluate its feasibility and safety.

Materials and Methods

Between October, 2019 and June, 2021, clinical data of consecutive patients aged over 18 years who underwent mini-invasive Bentall’s procedure via a 6-cm right anterior thoracotomy incision with a costal cartilage sparing technique in this center were reviewed. All included patients suffered from aortic sinus pathology with concomitant aortic valve disease without arch lesions documented by echocardiography. Computed tomography was performed as needed to assess the anatomy of the aortic root and the ascending aorta. Pulmonary function testing was frequently conducted.

Study Protocol

This study protocol was approved by the Ethics Committee of Zhongshan Hospital Fudan University and was consistent with the Declaration of Helsinki . All included patients signed an informed consent approved by the ethics committee.

Baseline and surgical characteristics, and perioperative outcomes were obtained retrospectively from our institutional database and were reviewed using a standard data collection form. The operative time was evaluated on the basis of aortic cross-clamping time and duration of cardiopulmonary bypass. The operative characteristics and perioperative outcomes (including surgical death, blood transfusion requirement, redo for bleeding, low cardiac output syndrome, prolonged mechanical ventilation of more than 72 h, new-onset cerebrovascular adverse events, acute kidney injury requiring hemodialysis, and length of ICU stay and postoperative hospital stay) were analyzed. The definitions and variables selected were based on The Society of Thoracic Surgeons Database definitions.

Patients were regularly followed up at 1-, 3- and 6-month following surgery and in 6-month intervals thereafter. Follow-up data were obtained through clinic visits or telephone interviews. Follow-up results included survival, reoperation, New York Heart Association (NYHA) functional class, and echocardiographic data.

Surgical Procedure

Surgery was performed under general anesthesia with double-lumen endotracheal intubation. Transesophageal echocardiography (TEE) and cerebral oximetry were initiated. Soft pads were put under the right side of the patient’s body with an inclination of 15–30°. Defibrillation electrode pads were placed behind the right scapula and on the 5th intercostal space of left anterior axillary line. The patient was prepped from above the clavicles to the knees bilaterally.

A femoral or axillary platform was utilized to establish the cardiopulmonary bypass (CPB). A 2–3 cm incision was made in the inguinal crease preferably on the right side, and a 5–0 Prolene purse-string suture was placed on the femoral or axillary artery and femoral vein. After heparinization, a Seldinger technique was utilized to cannulate the femoral/axillary vessels. The femoral/axillary artery was cannulated with a 16–19 Fr arterial cannula, and the femoral vein with a 24 Fr venous cannula. TEE was used to aid placement of the venous cannula in the superior vena cava.

A 6-cm incision (main incision) in the second intercostal space, starting two fingers lateral to the sternal border and extending laterally, was made, and the right pleural space was entered after one-lung (left lung) ventilation. The right mammary artery and vein were not transected, nor was rib or costal cartilage resection performed. Afterward, a soft tissue retractor (LAP Protector FF1210, Hakko Co., Ltd., Nagano, Japan) was inserted, and an intercostal rib spreader (Valve XS, Aesculap, Inc., PA, United States) was used to provide further visualization. Another incision for a 5-mm port (utility port) in the fourth or fifth intercostal space of right middle axillary line was made. After identifying the phrenic nerve, the pericardium was opened over the aorta and extended down toward the inferior vena cava. The pericardial stay sutures were placed and were clamped to the soft tissue retractor.

The CPB was initiated at 32–36°C using a closed-membrane oxygenator and roller pump. Venous drainage was augmented with vacuum assistance, applying a negative pressure of 30–70 mmHg as needed to decompress the right heart. A left ventricular vent passed through the utility port and was placed through the right superior pulmonary vein. Trans -incisional direct aortic cross-clamping was performed, utilizing a flexible and retractable shaft cross-clamp (Novare Surgical Systems, Cupertino, CA, United States). Myocardial protection was achieved using a modified Del Nido cardioplegia solution (4 parts blood to 1 part cardioplegia) at 4°C via direct coronary anterograde perfusion. The initial dose of anterograde cardioplegia infused was at 20 mL/kg. Additional doses will be administered at 90 min.

The aortotomy (H-shaped incision) was made at the point of the antegrade needle insertion. The proximal aorta was transected at the level of the sinotubular junction, and the amount of the distal ascending aorta removed was tailored on the basis of the pathology. Three commissural Prolene stay sutures were placed, which allowed exposure and rotation of the aorta toward the field of vision. A gauze pad was placed in the left ventricle temporarily to collect any debris. The leaflets were excised and calcification in the aortic annulus was debrided as necessary. The decision to implant mechanical prosthetic valve or bio-prosthetic heart valve was influenced by each patient’s demographic and clinical profile (i.e., age, peptic ulcer bleeding, the size of the aortic valve annulus). The size of the prosthetic valve was based on intraoperative actual measured values using the valve sizer. It was very important to implant a sufficiently large prosthetic valve in adult patients. In the case of implanting a mechanical prosthetic valve, a vascular graft with a mechanical prosthetic valve (Aortic Valved Graft Medtronic Inc., Minneapolis, United States; SJM Masters Series, St. Jude Medical Inc., St. Paul, MN, United States) was typically used; whereas a vascular graft (Terumo Cardiovascular Group, Tokyo, Japan; MAQUET Cardiovascular, Wayne, NJ, United States) was frequently used and a bioprosthetic valve was sewn into the graft using a running 4–0 polypropylene when bio-prosthetic heart valve was required. The annular sutures were placed with a double-armed 2–0 poly (ethylene terephthalate) suture with gasket and an interrupted mattress suturing technique, beginning with the commissural sutures followed by the left, non-coronary, and right sutures, respectively (see Figures 1A,B ). A knot setter was usually required to tie the knots.

Figure 1. Right minithoracotomy Bentall procedure. (A,B) The images show the annular sutures using a double-armed 2–0 poly (ethylene terephthalate) suture with gasket and an interrupted mattress suturing technique; (C) the image shows the anastomosis of the left main coronary-graft with a running fashion using 5–0 polypropylene; (D) the image shows the anastomosis of the right main coronary-graft with a running fashion using 5–0 polypropylene; (E) the image shows the distal anastomosis of graft-native ascending aorta with a running fashion using 4–0 polypropylene; (F) the image shows that the left ventricle and the graft were de-aired with a venting needle in the root of the aorta before the cross clamp was removed.

The aortic root was then exposed with stay sutures. The coronary buttons were constructed and retracted using stay sutures, and the remaining portion of aortic sinuses was removed. The anastomotic site of coronary buttons on the graft was determined with the heart filled and the graft distended. The left main coronary anastomosis (see Figure 1C ) was then completed with 5–0 polypropylene followed by the right main (see Figure 1D ). Sutures were started on the posterior aspect of the anastomosis. These suture lines were continuous, but they were intermittently tightened using a nerve hook to avoid the suture from becoming loose. A small autologous pericardial strip was placed between native coronary button and the graft.

The length of the graft was determined with the heart filled and the graft distended. The distal anastomosis of graft-native ascending aorta was completed in a running fashion using 4–0 polypropylene. These suture lines were continuous (see Figure 1E ), but they were intermittently tied to avoid the suture from becoming loose. Hemostatic glue was placed around the suture line for additional hemostasis. A temporary epicardial ventricular pacing wire was placed on the inferior aspect of the right ventricle before releasing the cross-clamp. Carbon dioxide was infused into the operative field through the utility port at a flow of 0.5 L/min during the entire procedure. The left ventricle and the graft were de-aired with a venting needle in the root of the aorta (see Figure 1F ) and under TEE guidance, and the cross-clamp was then removed.

Transesophageal echocardiography was used to meticulously evaluate ventricular function, prosthetic valve function, and the blood flow at the anastomoses of coronary arteries-graft. After discontinuing CPB and administering protamine, decannulation was performed. The purse-string sutures were tied and the femoral/axillary artery purse-string was reinforced with a 5–0 Prolene suture. After hemostasis was obtained, a pleural chest tube and a flexible pericardial tube were placed. The chest tubes along with the pacing wire were exited through the utility port. An On-Q pain relief system (I-Flow Corporation, Lake Forest, CA, United States) was inserted in each patient to provide pain relief. Two catheters were placed in the interspace to deliver 0.25% bupivicaine for 72 h. The incision was closed in the usual fashion.

Statistical Analysis

Statistical analysis was performed with the SPSS statistical package version 22.0 (SPSS Inc., Chicago, IL, United States). Categorical data were expressed as frequency distributions and single percentages and were compared between groups using Fisher’s exact test if the expected frequency was <5 or the chi-square test. Normally distributed continuous variables were expressed as the mean ± standard deviation and were compared between groups using an independent-samples t -test; non-normally distributed continuous variables were expressed as median and interquartile range (IQR) and were compared between groups with the Wilcoxon rank sum test. A two-sided p -value less than 0.05 was considered statistically significant.

Study Population

During this study period, a total of 481 Bentall procedures were carried out at our institution, including 450 full sternotomy procedures, 16 ministernotomy, and 15 right minithoracotomy. Fifteen consecutive patients who underwent right minithoracotomy Bentall procedure were identified. There were 15 male patients with the age ranging 19.0–69.0 years with a median of 58.0 years. This series included 2 patients with a history of percutaneous coronary intervention without requiring bypass grafting determined by preoperative invasive coronary angiography. Six patients were identified as Marfan’s syndrome, and another 8 had congenital bicuspid aortic valve. Severe aortic insufficiency was reported in all 15 patients, of whom 3 were diagnosed with concomitant severe aortic stenosis. The diameter of the aortic sinus ranged from 47.0 to 80.0 mm with a median of 49.5 mm, with no significant dilatation of the ascending aorta (median, 40.5 mm). The median left ventricular ejection fraction was 61.5%, with the median left ventricular endo-diastolic diameter of 60.5 mm (ranging 54.0–64.0 mm). Notably, one patient with Marfan’s syndrome had a previous mitral valve repair via a full median sternotomy approach. The detailed baseline characteristics are shown in Table 1 .

Table 1. Baseline characteristics.

Surgical Variables and Intraoperative Outcomes

All 15 patients underwent mini-invasive Bentall procedure via the right anterior thoracotomy approach (see Figure 1 ). The aortic cross-clamp time ranged from 80.0 to 105.0 min with a median of 95.0 min. The median duration of cardiopulmonary bypass was 138.5 (IQR, 130.5–163.5) min. Types and sizes of prosthetic valves are listed in Table 2 . Adequate surgical exposure was obtained in all 15 patients, and there were no conversions to sternotomy performed. Intraoperative TEE immediately after the discontinuation of CPB showed that no instances of periprosthetic fistula were recorded.

Table 2. Procedure characteristics.

One patient with Marfan’s syndrome without a previous cardiac procedure underwent an immediate repeat operation due to the left coronary kinking determined by TEE examination before the discontinuation of CPB. This was the first right minithoracotomy Bentall procedure in this center. After re-block perfusion with myocardial protection using the modified Del Nido cardioplegia solution, the anastomosis of native left coronary button-graft was removed, further dissociation the left main coronary from the surrounding tissue was performed, and the anastomosis of native left main coronary button-graft was then reconstructed. Afterward, successful weaning off bypass was recorded.

In-Hospital Outcomes

The mechanical ventilation time ranged from 7.0 to 46.0 h with a median of 12.5 h. The median drainage volume in the first 24 h following surgery was 200.0 (IQR, 117.0–552.5) mL, with no redo for bleeding. Three (20.0%) patients received blood transfusion. There were no significant postoperative complications noted, including surgical death, low cardiac output, acute kidney injury requiring hemodialysis, and cerebrovascular accidents ( Table 3 ). The length of ICU stay ranged from 0.5 to 4.0 days with a median of 1.5 days. All 15 patients were discharged smoothly, with the mean length of postoperative hospital stay of 5.8 ± 1.2 days.

Table 3. Perioperative and follow-up results.

Follow-Up Results

All 15 patients received a follow-up visit with a median duration of 8.0 (IQR, 6.0–10.0) months. The clinical symptoms resolved, and no death or re-intervention was recorded. The shortest follow-up period was 6 months. By 6 months following surgery, NYHA functional class significantly decreased from the preoperative value ( p < 0.001), with no patients in class III or IV ( Figure 2 ). The incision healed well ( Figure 3 ), and no complications such as poor healing and infection were found. No cases of periprosthetic fistula or significant aortic valve or mitral regurgitation determined by TTE were recorded at follow-up.

Figure 2. NYHA functional class prior to surgery and 6 months following surgery. (A) NYHA class preoperatively and postoperatively per patient; (B) NYHA class (baseline vs. 6-m after surgery, p < 0.001). NHYA, New York Heart Association; Pt., patient.

Figure 3. Skin incision. The image shows a skin incision in the right minithoracotomy Bentall procedure (where the white dotted arrow is pointing) and a skin incision in previous mitral valve repair via full median sternotomy (where the black arrow with a solid line is pointing).

With mini-invasive aortic valve surgery becoming more common, surgeons worldwide have added more complex pathology to their mini-invasive techniques to allow patients the benefit of not having to undergo a full sternotomy ( 9 , 10 ). Various mini-invasive approaches, including right parasternal incision, upper T incision, upper J incision, S-shaped partial sternotomy, L incision, as well as Z-, I-, and C-shaped ministernotomy incisions, have been used for surgery of the aortic root and the ascending aorta ( 9 ). Much of the literature reviewed showed the feasibility and favorable results of mini-invasive techniques for complex aortic pathology involving some type of partial sternotomy. Previously, Byrne et al. ( 4 ) reported a series of 290 consecutive patients who underwent aortic valve, aortic root, and/or ascending aorta replacement via either a partial upper sternotomy (87%) or a parasternal (13%) approach. They found that this approach was feasible with an acceptable incidence of complications without compromising the surgical procedure. Afterward, Tabata et al. ( 11 ) performed a 5 years follow-up of 128 patients who had ascending aortic, arch, and root surgery via an upper ministernotomy, and emphasized that this approach for complex aortic pathology was feasible and achieved an excellent late outcome. Recently, Perrotta et al. ( 9 ) reviewed the literature on various mini-invasive approaches for aortic root and ascending aorta surgery, and found that not only was a mini-invasive technique for complex aortic pathology feasible, but there were significant advantages when compared to full sternotomy. A right anterior minithoracotomy approach, with no performing any type of sternotomy, may lead to less surgical trauma and better outcomes. Johnson et al. ( 8 ) in a retrospective review of seven patients, described elective Bentall procedure performed through a right minithoracotomy approach and received favorable outcomes. It’s worth noting that in that series, video guidance was used in all patients, automated suturing technology was applied in some cases, and total circulatory arrest was used in all cases of distal anastomosis. Recently, a case report ( 12 ) presented a right minithoracotomy technique for Bentall procedure with conventional instruments and suturing techniques. We have completed 15 right minithoracotomy Bentall procedures during the last 1 year and a half. To the best of our knowledge, this is probably the largest experience of adult patients undergoing the right minithoracotomy Bentall procedure published to date. In our series, conventional instruments and suturing techniques were used without total circulatory arrest for distal anastomosis. Neither rib disarticulation was done, nor was the right internal mammary artery sacrificed. In this series, shortened length of intensive care unit as well as hospital stay coincided with neither in-hospital death nor neurological complication nor bleeding complication, which suggested that the right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. During a follow-up period of at least 6 months, all 15 patients survived without reoperation, and their NYHA functional class improved, with no periprosthetic fistula or significant aortic valve regurgitation found. Results indicated the safety and effect of the right minithoracotomy Bentall procedure.

The major disadvantage of the right minithoracotomy approach for Bentall procedure is the longer circulatory arrest time required compared with sternotomy approaches. The median CPB time in this series was 138.5 min, which is much shorter than the time of 202.9 ± 47.8 min in the case series by Johnson et al. ( 8 ). Similarly, the median cross-clamp time in this series was 95.0 min, which is meaningfully shorter than the mean cross-clamp time of 161.9 ± 32.1 min reported in their study ( 8 ). The reduction in the aortic cross-clamp time and CPB time may be due to the increasing experience with this technique and standardization of the operative steps. In this center, the right minithoracotomy AVR has become a common practice over the years with an annual volume of over 300 cases, and Bentall procedure through sternotomy was carried out about 300 cases per year. In this series including 15 right minithoracotomy Bentall procedures, 14 were carried out by Professor CSW and one by Professor HL. Professor CSW has completed Bentall procedure through sternotomy over 50 cases per year and right minithoracotomy AVR about 200 cases per year, and Professor HL has completed Bentall procedure through sternotomy over 20 cases per year and right minithoracotomy AVR of over 30 cases per year. We believed that the right minithoracotomy Bentall procedure should be performed by cardiac surgeons who have gained sufficient experience with right minithoracotomy AVR and who also had rich experience in Bentall procedure through sternotomy.

In our opinion, the right minithoracotomy Bentall procedure should be performed in carefully selected patients. In this initial clinical experience, selection criteria included patients with normal or near normal left ventricular ejection fraction, no significant coronary artery disease requiring bypass grafting or with concomitant other cardiac procedures, and aortic arch pathology requiring no greater than a hemiarch resection. We avoided patients with aortic dissection or intra-mural hematoma, or surgical procedures requiring aortic valve preservation. It was also preferable not to use this technique to operate in patients with peripheral vascular disease. A preoperative CT scan of the chest was performed in all patients to better delineate the anatomy as well as determine the presence and extent of calcification of the aorta. Patients with aortas positioned left of the midline on preoperative imaging were not good candidates for this approach. Patients were excluded from this approach if they had heavily calcified ascending aorta or porcelain aorta ( 13 ), thoracic deformity, anomalous origin of coronary artery, and poor pulmonary function. This approach was not recommended when patients underwent previous right thoracic surgery. Previous studies ( 14 ) reported that a prior sternotomy was a relative contraindication to this procedure. In fact, one patient in this series who had a history of mitral valve repair via a full median sternotomy underwent the right minithoracotomy Bentall procedure and received favorable results. We believed that a prior mitral valve procedure with a full median sternotomy was not a contraindication to the right minithoracotomy Bentall procedure, but a prior aortic valve procedure with or without ascending aortic procedure with a full median sternotomy may be a relative contraindication to this approach. In addition, patients or the family agreed to receive this rarely performed, mini-invasive approach for complex aortic root surgery, and signed the informed consent.

Notably, only a minority of patients (3.1%) who underwent Bentall procedure received the right minithoracotomy approach. There may be several reasons behind it. In this initial clinical experience, only extremely “healthy” patients (with a normal ejection fraction and having relatively few comorbidities) were chosen to undergo this approach, and only two experienced cardiac surgeons have carried out this procedure. The successful experience of Professor HL in carrying out the right minithoracotomy Bentall procedure suggested this technique may be adopted and reproduced, and it inspired more surgeons to use this sternal sparing approach for Bentall procedure. In fact, Doctor QJ has completed one right minithoracotomy Bentall procedure. The patient was discharged on postoperative day 5. The patient received routine follow-up at 1-month following surgery, was asymptomatic, and was carrying out his daily activities. This again suggested that the right minithoracotomy Bentall procedure may be adopted and reproduced. Patient concerns about safety and effect of this initial approach for Bentall surgery may also be a contributing factor. We believed that with the accumulation of experience and the increase of successful cases, more cardiac surgeons will carry out this procedure, and more patients will accept this approach.

In this center, a femoral rather than an axillary platform was utilized preferably to establish the CPB as small inner diameter of the axillary artery of Chinese patients made it difficult to cannulate with above 16 Fr arterial cannula. In this series, no retrograde iatrogenic aortic dissection associated with femoral artery cannulation was observed. Notably, pericardial stay sutures should be employed liberally in order to mobilize the aorta prior to the cross-clamp. The bottom jaw of the aortic cross clamp should be placed above the right pulmonary artery to provide more operating space. It was very important to perform an excellent anastomosis at each site and in particular coronary button anastomosis. A small autologous pericardial strip placing between native coronary button and the graft was introduced to reduce the risk of this complication. More critically, the left and right main coronary should be dissociated fully, a serious lesson for us, to avoid coronary kinking after anastomosis. Via the right anterior thoracotomy approach, the aortic root was replaced in all 15 patients, and the distal extent of reconstruction was above the level of transverse sinus and reached the level of the right pulmonary artery. Meticulous attention to maintaining hemostasis was critical in this procedure, because bleeding will be more difficult to control, particularly at the left and the right main coronary artery anastomoses. Multimodal analgesic therapy, including intercostal nerve blocks, peri-incisional lidocaine patches, and acetaminophen, may contribute to reducing narcotic pain medicine requirements and promoting early mobilization.

The current study was subject to the limitations inherent in a single-center, retrospective study design with a short follow-up. A control group including patients undergoing Bentall procedure via full or partial sternotomy was not established, and the number of patients undergoing the right minithoracotomy Bentall procedure was relatively small (15 patients), implying potential weakness of the results. Finally, the patients studied in this series had a normal ejection fraction and had relatively few comorbidities suggesting that the study results might not be generalizable to sicker patients undergoing this approach. As surgeon experience increases, selected sicker patients may be candidates for this approach.

The present study demonstrated that the right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. It should be considered as an option in carefully selected patients requiring aortic root replacement.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

Ethics Statement

The studies involving human participants were reviewed and approved by the Ethics Committee of Zhongshan Hospital Fudan University. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

QJ, YW, and FL contributed equally in the data collection, statistical analysis and manuscript drafting. YY, JL, XS, ZY, and SP participated in data collection, patient follow-up and manuscript revision. CW and HL were responsible for the study design, manuscript revision and consultation. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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7. Miceli A, Murzi M, Gilmanov D, Fugà R, Ferrarini M, Solinas M, et al. Minimally invasive aortic valve replacement using right minithoracotomy is associated with better outcomes than ministernotomy. J Thorac Cardiovasc Surg. (2014) 148:133–7. doi: 10.1016/j.jtcvs.2013.07.060

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Keywords : aortic root replacement, Bentall’s procedure, minimally invasive cardiac surgery, right anterior minithoracotomy approach, costochondral cartilage sparing

Citation: Ji Q, Wang Y, Liu F, Yang Y, Li J, Sun X, Yang Z, Pan S, Lai H and Wang C (2022) Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing. Front. Cardiovasc. Med. 9:841472. doi: 10.3389/fcvm.2022.841472

Received: 22 December 2021; Accepted: 08 February 2022; Published: 02 March 2022.

Reviewed by:

Copyright © 2022 Ji, Wang, Liu, Yang, Li, Sun, Yang, Pan, Lai and Wang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Hao Lai, la[email protected] ; ChunSheng Wang, [email protected]

† These authors have contributed equally to this work and share first authorship

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Article Contents

Introduction, materials and methods, conclusions, author contributions, abbreviations.

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Long-term follow-up of Bentall procedure using the Perimount bioprosthesis and the Valsalva graft

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Ilaria Chirichilli, Francesco Giosuè Irace, Salvatore D’Aleo, Giulio Folino, Luca Paolo Weltert, Raffaele Scaffa, Saverio Nardella, Ruggero De Paulis, Long-term follow-up of Bentall procedure using the Perimount bioprosthesis and the Valsalva graft, Interactive CardioVascular and Thoracic Surgery , Volume 30, Issue 5, May 2020, Pages 679–684, https://doi.org/10.1093/icvts/ivaa007

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Bentall procedure is the gold standard for aortic root pathologies when valve repair is not feasible. The development of durable bioprosthetic valves and improved vascular conduits allowed the implementation of bioprosthetic composite grafts; hereby, we performed a retrospective analysis of long-term follow-up of Bentall procedure using the Valsalva graft and the Perimount Magna Ease prosthesis.

From June 2000 to March 2019, 309 patients received an aortic root and valve replacement with a bioprosthetic composite graft. The mean age was 69 ± 6.9 years, and the majority were men (88%); most of them were affected by aortic stenosis (86%) and the mean aortic root diameter was 48.6 ± 5.5 mm.

Freedom from cardiac death was 76.8% [confidence interval (CI) 32.5–94.0] at 16 years. Freedom from thromboembolism, haemorrhage, structural valve deterioration and infective endocarditis was 98.2% (CI 96.0–98.9), 95.2% (CI 87.1–98.2), 87.5% (CI 63.2–97.1) and 79.6% (CI 45.3–95.6) at 16 years, respectively. Freedom from reoperation was 74.7% (CI 41.9–90.6).

These data indicate that, in experienced centres, the Bentall procedure is a safe and effective intervention. This is the first long-term follow-up that analyses the results after implantation of a composite graft made with the Perimount Magna Ease aortic valve and the Valsalva graft.

The modified Bentall–De Bono procedure is still the gold standard in different scenarios of aortic root and valve pathology. Several modifications to the classic Bentall procedure [ 1 ] have been introduced over the time. Historically, the majority of Bentall procedures were performed with mechanical valved conduits. However, in the past decades, the target patients for Bentall procedures have changed and the use of biological valved conduit has expanded [ 2 ]. Although thromboembolism, valve durability and endocarditis are still the major causes of prosthetic valve-related late postoperative morbidity and mortality, the Carpentier-Edwards pericardial valve prosthesis passed the proof of time and has shown good performance even at long-term follow-up [ 3 , 4 ]. Since 2001, our group has systematically performed the Bio-Bentall procedure using the Valsalva graft (Terumo Aortic, Glasgow, UK) [ 5 ]. Valsalva pseudosinuses might offer several advantages. Because of eddy currents formation, they could reduce the stress on the bioprosthesis leaflets and commissures. Furthermore, the presence of vortices would tend to wash the transitional area between the prosthetic valve and the Dacron conduit, potentially reducing the incidence of thromboembolism. Given the graft resilience, Valsalva pseudosinuses might also decrease the stress on the coronary button anastomoses [ 6–9 ]. We reviewed our experience with the Valsalva graft in combination with Perimount or Magna Ease aortic biological valve to verify the beneficial effects on durability and valve-related complications.

Patient population

Between June 2000 and March 2019, 309 patients underwent a Bentall procedure in our Institution using the Perimount or the Magna Ease aortic bioprosthesis combined with the Valsalva graft (Gelweave Valsalva, Terumo Aortic). All patients suitable for Bentall procedure with a biological conduit were enrolled; no further exclusion criteria were applied to the population. The mean age was 68.9 ± 6.9 years, and 271 patients were male (88%). All patients had aortic root aneurysm with aortic valve pathology, mostly with severe aortic stenosis (86%). Seventy-two patients had bicuspid aortic valve (23%). The mean aortic root diameter was 48.6 ± 5.5 mm. Sixteen patients had an acute type A aortic dissection (5.2%). The mean EuroSCORE II value was 2.7 ± 0.9% ( Table 1 ).

Preoperative clinical, echocardiographic and CT scan characteristics of patients

CT: computed tomography; SD: standard deviation.

Surgical technique

The use of the Valsalva™ graft does not require any changes in the standard surgical technique. The site chosen for cannulation depends on the anatomy and the extent of aneurysm. Proper creation and mobilization of the coronary buttons will prevent kinking and twisting. After the annulus is sized, pledgeted stiches are placed on the ventricular side and then placed on a single stroke through the valve sewing ring and the collar of the graft. The coronary ostia are reattached to the graft by using the ‘open’ technique (Carrel button). Generally, biological conduits were manufactured by selecting a Valsalva graft 3 or 5 mm larger than the aortic prosthesis. The most common graft implanted was the 28 mm (52%), and the vast majority of the valves were 23 and 25 mm (33% and 48%, respectively). The mean cardiopulmonary bypass time was 99.6 ± 35.7 min, and the mean cross-clamp time was 80.2 ± 25.9 min ( Table 2 ).

Operative data

CPB: cardiopulmonary bypass; SD: standard deviation.

The mean clinical and echocardiographic follow-up was 60 ± 45 months (range from 1 to 204 months). The data were collected by outpatient visits and personal telephone interviews. Morbidity events were defined according to the ‘Guidelines for Reporting Mortality and Morbidity After Cardiac Valve Interventions’ drafted by the Councils of the American Associations for Thoracic Surgery (AATS), the Society of Thoracic Surgeons (STS) and the European Association for Cardio-Thoracic Surgery (EACTS). Structural valve deterioration (SVD) includes dysfunction or deterioration involving the operated valve (exclusive of infection or thrombosis), as determined by reoperation, autopsy or clinical investigation with periodic echocardiographic surveillance. Valve thrombosis is defined as any thrombus not caused by infection attached to or near an operated valve that occludes part of the blood flow path, interferes with valve function or is sufficiently large to warrant treatment. Embolism is defined as any embolic event that occurs in the absence of infection after the immediate perioperative period. Embolism may be manifested by a neurologic event or a non-cerebral embolic event. A neurological event includes any central, new neurological deficit, whether temporary (transient ischaemic attack) or permanent (stroke) and whether focal or global that occurs after the patient emerges from anaesthesia. A non-cerebral embolic event is an embolus documented operatively, at autopsy, or clinically that produces signs or symptoms attributable to complete or partial obstruction of a peripheral artery. A bleeding event is defined as any episode of major internal or external bleeding that causes death, hospitalization or permanent injury or necessitates transfusion [ 10 ].

Statistical analysis

A custom-made prospective database software was developed to archive and trace follow-up during these years. Continuous data are expressed as means and standard deviations. Categorical data are presented as absolute values and percentages. When needed differences among variables were assessed with unpaired Students’ t -test or Kruskal–Wallis test for continuous variables [the latter was chosen when assumptions of one-way analysis of variance (ANOVA) were not met] and with χ 2 or Fisher’s exact test as appropriate for categorical variables (the latter was chosen when count of events in contingency table was under 10). The time-dependent variables were analysed using the Kaplan–Meier method, and the number at risk is reported in graphs for each time frame (patients are censored at the time of event and we count only last follow-up time as event from patients without event in a Kaplan–Meier analysis, so-called inverse Kaplan–Meier). In all cases, a standard P -value of ≤5% was considered statistically significant. SPSS (version 21, IBM Corporation, Somers, NY, USA) and Excel (Microsoft, Redmond, WA, USA) were used for data analysis.

Early outcome

There were 5 perioperative deaths (1.6%) within 30 days after surgery: 2 patients had multi-organ failure, 1 had mediastinitis and subsequent sepsis, 1 had cerebral ischaemia and 1 had cerebral haemorrhage.

Long-term outcome

Follow-up was 97% complete, with 9 patients lost. Cumulative follow-up time was 1568 patient-years. There were 37 late deaths; so long-term overall survival (including both early and late deaths) was 88.6% [95% confidence interval (CI) 83.9–92–0], 81.4% (CI 73.5–88.4), 65.4% (CI 43.4–80.6) and 54.5% (CI 27.5–75.2) at 5, 10, 15 and 16 years. Freedom from cardiac death was 98.7% (CI 95.6–99.5), 98.7% (CI 95.6–99.5), 92.1% (CI 65.0–97.4) and 76.8% (CI 32.5–94.0) (Fig.  1 ). Freedom from thromboembolism was 98.2% (CI 96.0–98.9) at 5, 10, 15 and 16 years. Freedom from haemorrhage was 97.5% (CI 95.0–98.6) at 5 years and 95.2% (CI 87.1–98.2) at 10, 15 and 16 years (Fig.  2 ). Freedom from SVD was 100% at 5 and 10 years, 87.5% (CI 63.2–97.1) at 15 and 16 years, and freedom from infective endocarditis was 97.0% (CI 93.7–98.6) and 96.0% (CI 91.8–98.9) at 5 and 10 years and 79.6% (CI 45.3–95.6) at 15 and 16 years (Figs  3 and 4 ).

Freedom from overall survival (blue line) and cardiac death (red line).

Freedom from thromboembolism (blue line) and freedom from haemorrhage (red line).

Freedom from structural valve deterioration.

Freedom from endocarditis.

Eight patients required reoperation (2.6%) after a median time of 64.5 months, range between 4 and 173 months; 7 of them had infective endocarditis and 1 had degeneration of the bioprosthesis. Freedom from reoperation was 98.1% (CI 94.9–99.3) at 5 years, 97.1% (CI 92.8–98.8) at 10 years and 74.7% (CI 41.9–90.6) at 15 and 16 years (Fig.  5 ).

Freedom from reoperation.

The introduction of aortic root replacement with a composite graft according to the classic and modified Bentall techniques improved significantly the postoperative outcome, providing satisfactory early-, mid- and long-term results, both for biological and mechanical conduits [ 11–16 ]. The Bentall technique has several advantages: first, all diseased aortic tissue is eliminated from the aortic root; second, the operation is conceptually simple, well codified and easily reproducible. However, the replacement of the aortic valve with valve prosthesis is associated with a series of possible postoperative complications such as thrombosis, SVD, endocarditis and haemorrhage. Indeed, every valve prostheses introduce a new disease process. Practically, the choice for valve replacement is between a mechanical prosthesis and a biological prosthesis. Randomized trials comparing these 2 categories of prostheses consistently found similar survival, no significant difference in rates of valve thrombosis and thromboembolism, higher rates of bleeding with mechanical prostheses and higher rates of reintervention with bioprostheses [ 17 ]. Nevertheless, the use of biological valve conduits in patients undergoing aortic root surgery has markedly increased in the last decade. This trend is probably the result of several factors: first of all the improved long-term durability of newer valve models [ 18 ], the increasing age of patients with aortic valve and root disease, the mandatory need for long-term anticoagulation for mechanical prostheses, which inevitably has an impact on lifestyle and quality of life, and the recent development of transcatheter valve-in-valve procedures [ 19 ]. This last aspect, however, deserves a word of caution in the use of biological prostheses in younger patients because of lack of long-term data on valve-in-valve durability or need for immediate anticoagulant therapy [ 20 ].

Moreover, according to the most recent guidelines for the management of patients with heart valve diseases, the choice between a mechanical and a biological valve in adults is no longer mainly determined by the age cutoff [in this setting, the American College of Cardiology/American Heart Association guidelines recommend a lower age cutoff (50 years) compared with the ESC guidelines (age <60 years for aortic) for recommending mechanical rather than biological prostheses] [ 21 ], but rather it should be discussed in detail with the informed patient, cardiologists and surgeons, taking into account not only the estimated risk of anticoagulation-related bleeding and thromboembolism with a mechanical valve versus the risk of SVD with a bioprosthesis but also considering the patient’s lifestyle and preferences. In particular, the recommendations in favour of a bioprosthesis include in Class I—Level of Evidence C, a desire of the informed patient, when good-quality anticoagulation is unlikely, or in case of high bleeding risk and reoperation for mechanical valve thrombosis despite long-term anticoagulation control [ 17 ].

Furthermore, in the last decades, aortic valve-sparing techniques have widely spread in the field of aortic root pathologies. However, compared to Bentall procedure, valve-sparing aortic root replacements are less appealing for the elderly patients and are technically more demanding with possible longer operative times.

These data support the extended use of bioprosthetic valves, not only in patients with isolated aortic valve diseases but also in those with combined aortic valve and root diseases.

Although thromboembolism, valve durability and endocarditis are still the major causes of prosthetic valve-related late postoperative morbidity and mortality, the Carpentier-Edwards Perimount and Magna Ease aortic prostheses have shown good performance even at long-term follow-up [ 3 , 4 ]. Matching these satisfactory results with the advantages of Valsalva graft, we reviewed our experience with the Valsalva graft in combination with such biological aortic prostheses to verify the beneficial effects on durability and valve-related complications. In fact, the Valsalva graft introduced by one of us in 2000 [ 5 ] (Gelweave Valsalva, Terumo Aortic) with the presence of pseudosinuses appears to play a beneficial role in regulating aortic root blood flow. It also creates more space between the bioprosthetic valve struts and the coronary buttons and may potentially decrease the risk of coronary button complications. Furthermore, the presence of vortices would tend to wash the transitional area between the prosthetic valve and the Dacron conduit, potentially decreasing the incidence of thromboembolism [ 8–9 ]. Another potential advantage is in the greater clearance of the coronary ostia in case a transcatheter aortic valve replacement (TAVR) valve in valve would become necessary at a later stage.

This retrospective longitudinal analysis showed a minimal incidence of thromboembolism and haemorrhage (freedom from thromboembolism 98.2%), (freedom from haemorrhage 95.2%), a low incidence of SVD (freedom from SVD 87.5%) and a satisfactory incidence of cardiac death (freedom from cardiac death 76.8%) at a mean follow-up of 16 years.

Limitations

In most cases, very few events were reported, which is a potentially major limitation of the power of the study. Moreover, as the number at risk is <10% of the initial cohort, data should be taken with caution.

These data indicate that, in experienced centres, the Bentall procedure performed using the Perimount or the Magna Ease aortic valve and the Valsalva graft is a safe and effective intervention. This is the first long-term follow-up, which analyses the results of implantation of the composite biological conduit. Further years of follow-up and an increased number of patients are required to provide the validation with regard to the long-term outcomes.

Conflict of interest: As inventor of the Valsalva graft described in the manuscript, Ruggero De Paulis has received in the past royalties from Terumo Aortic. All other authors declared no conflict of interest.

Ilaria Chirichilli: Conceptualization; Methodology; Writing—original draft. Francesco Giosuè Irace: Data curation; Methodology. Salvatore D’Aleo: Data curation. Giulio Folino: Data curation. Luca Paolo Weltert: Formal analysis. Raffaele Scaffa: Resources. Saverio Nardella: Resources. Ruggero De Paulis: Conceptualization; Supervision.

Presented at the 33rd Annual Meeting of the European Association for Cardio-Thoracic Surgery, Lisbon, Portugal, 3–5 October 2019.

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Confidence interval

Structural valve deterioration

• aortic valve
• thromboembolism
• conduit implant
• bioprosthesis
• repeat surgery
• tissue transplants
• coronary inclusion technique
• supraaortic valve area

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Bentall: A complex and high risk surgery

The Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), Kolkata, set another milestone in cardiovascular surgery through completing the complex ‘Bentall procedure’. This surgery was performed for the first time in East India.

Bentall surgery was performed on a patient suffering from ‘Type-A Aortic dissection ’, along with a rare disorder of muscular-skeletal system called ‘Limb-Girdle Muscular Dystrophy’.

Type-A Aortic dissection is a fatal condition where the aorta layers (of the main artery of the body) are separated from each other. This is a rare medical condition and is also a medical emergency .

Since this case had dual complications, doctors at RTIICS decided to perform a Bentall surgery. Dr. Atanu Saha, Consultant -Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), headed the team of surgeons that completed the surgery after 11 gruelling hours.

Dr. Atanu Saha: “Aortic dissection is always fatal if not operated immediately and the challenge lies in its early detection and surgical treatment. In the case of Mr. Kamala Padi (the patient), considering the complexity of the situation, Bentall surgery was the only option. This is considered as a complex surgery. Bentall surgery was successfully performed for the first time on a patient suffering from these dual rare conditions in East India.”

Mr. Kamal Padi, the patient, expressed his gratitude to the team of doctors: “I had lost all hopes of surviving. I was suffering from this condition for quite some time and was slowly losing my ability to walk. When I was diagnosed with this condition, I felt my world has come to an end. But, the doctors at RTIICS gave me confidence and hope, which makes me a healthy person today to face the world. My heartfelt thanks to doctors of RTIICS for giving me a new lease of life.”

A Bentall surgery is used to rectify problems with the aorta – the aorta has the important role of carrying oxygen-rich blood from the heart to every part of the body. A Bentall surgery replaces the damaged aorta and re-implants coronary arteries into the graft.

The Bentall surgery success highlights efforts of the Department of Cardiac surgery in RTIICS in expanding expertise and experience in complex cardiac procedures, and ensuring services offered to meet international standards.

Since the department started in 2000, it has performed more than 22,442 cardiac surgeries. The expert team of doctors strives to provide the finest care for its pediatric patients. The hospital regularly conducts free heart screening camps across the districts of West Bengal.

Dr. Atanu Saha , Consultant – Cardiac Surgery , Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), Kolkata

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Early and midterm outcomes of a bentall operation using an all-biological valved BioConduit™

Roxana botea.

1 Department of Cardiovascular Surgery, Rangueil University Hospital, Toulouse, France

2 Department of Cardiology, Rangueil University Hospital, 1, Avenue Jean Poulhès, TSA 50032, 31059 Toulouse Cedex, France

Yoan Lavie-Badie

Alexandru goicea.

3 Department of Cardiovascular Surgery, Nicolae Stancioiu Heart Institute, Cluj-Napoca, Romania

Jean Porterie

Bertrand marcheix, associated data.

The datasets and the materials used and analyzed during the current study are available from the corresponding author on reasonable request.

To analyze the midterm results of aortic root replacement using the valved, all biological, No React®, BioConduit™.

From 2017 to 2020, we prospectively followed 91 consecutive patients who underwent a Bentall procedure with a BioConduit™ valved graft in our institution. The primary outcomes were aortic bioprosthetic valve dysfunction and mortality according to Valve Academic Research Consortium 3 (VARC3).

Mean age was 70 ± 10 years and 67 patients (74%) were men. Ascending aortic aneurysm (72%), aortic valve regurgitation (51%) or stenosis (20%) and acute endocarditis (14%) were the main indications for surgery. Seventy-four patients (81.3%) were followed up at 1 year. The perioperative mortality was 8% (n = 8), the early, 1 year, mortality was 2% (n = 2) and the midterm mortality, at 4 years of follow up, was 4% (n = 3). Ten patients fulfilled the criteria for hemodynamic valve deterioration at 1 year (13%) and 14 for a bioprosthetic valve failure during the entire follow-up (17%).

Conclusions

We are reporting early and midterm results of Bentall procedures with the all-biological, valved, No-React® BioConduit™. To our knowledge, this is the first study reporting an early and midterm unexpectedly high rate of non-structural prosthetic hemodynamic deterioration. The rate of endocarditis and atrioventricular disconnections remain similar to previous studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-02073-5.

The Bentall procedure is the gold standard therapy in patients with either ascending aorta or aortic root aneurysm combined with aortic valve disease precluding a valve sparing procedure. [ 1 ]. The original technique described by Bentall and De Bono using a composite mechanical valved graft benefited from iterative refinements in order to overcome specific surgical drawbacks [ 2 ]. Nowadays, either preassembled or self-assembled conduits, associating tubular straight or Valsalva graft and biological or mechanical valve, are widely used [ 3 , 4 ]. As an alternative, a fully xenobiological stentless valved conduit, the Shelhigh NR-2000, was introduced in the late 1990’s and thereafter withdrawn from the market. Recently, a totally biological stentless conduits have been reintroduced in a modified version, using a porcine aortic valve and a bovine pericardial tube (BioIntegral™, BioValsalva™). The goal of our study was to investigate the early and midterm results of the Bentall procedure using BioIntegral™ BioConduit™ in our single-center experience.

Study design

It was a prospective observational study, without control-group, carried out from 2017 to 2020 in our tertiary centre.

Study population

All consecutive patients undergoing a Bentall procedure with the BioIntegral™ Surgical BioConduit™ No-React® in our institution (n = 91) were prospectively included during the study period. All patient data were collected from hospitals’ medical records. Cohort patients underwent an aortic root replacement with an all-biological graft in cases of complex endocarditis or redo surgeries, cases of patients who were not candidates for an autograft procedure but a mechanical graft was not indicated and in elderly patients with degenerative aortic root disease.

The study is conformed to the principles outlined in the Declaration of Helsinki. According to French law on ethics, patients were informed that their codified data would be used for the study. The patient also provided informed written consent for the publication of the study data. The Institutional Review Board of the Rangueil University Hospital of Toulouse, France, approved the study protocol and the publication of data (number RnlPH 2022-50) on the 7th of April 2022.

Surgical data

All interventions were performed by four senior surgeons. All patients were operated through median sternotomy. Standard cardiopulmonary bypass, aortic cross-clamp and anterograde and retrograde cold blood potassium-enriched cardioplegia were used in all patients. When an aortic arch replacement was performed, moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion through the right axillary artery were associated. After aortic cross-clamping, the aortic valve, the aortic root and the ascending aorta were excised, followed by aortic annulus decalcification when required. The coronary ostia were isolated with their buttons. After sizing of the aortic annulus, the prosthesis was chosen, with a trend in oversizing. The all-biological stentless valved bioconduit is designed to offer similar hemodynamics as the native aortic valve and theoretically aimed to insure a larger post-operative effective orifice area (EOA). The conduits’ No-React® treatment aims to reduce the grafts’ related infections and calcifications as well as to prevent remodeling and graft aneurysmal dilatation [ 5 – 7 ]. As the traditional glutaraldehyde preserved biological valves tend to calcify, the No-React® detoxification process promises to eliminate residual glutaraldehyde and to ensure stable tissue cross-linking, resulting in less or no calcification or tissue deterioration in the animal model [ 5 , 6 ]. A variety of BioConduit™ sizes between 21 to 29 mm were implanted. The trend of oversizing refers to choosing a conduit one-size oversized following the manufacturer’s recommendations, to achieve greater effective surface areas, avoiding mismatch [ 7 ]. Depending on operator preferences, two types of implantation techniques were used, either multiple single, interrupted, non-everting, reinforced U-stiches to implant the composite graft in supra-annular position (n = 33, 36%) or everting stitches to implant the prosthesis in intra-annular position (n = 58, 64%). Then, 2 holes were made in the tubular graft and both coronary ostia were reimplanted by running sutures (Prolene 6–0). Fibrin glue was used in most cases to reinforce sutures.

Imaging protocol

A post-operative transthoracic echocardiographic (TTE) assessment was performed before hospital discharge: 2D TTE standard views were obtained using a standard ultrasound system using a 1–5 MHz probe (VIVID S70, GE Healthcare). A new TTE assessment was conducted at 1 year, using the same system. EOA was calculated by the continuity equation method. Aortic annulus diameter was measured at mid-systole, from the parasternal long-axis view, at the level of the prosthetic annulus, in a zoomed mode, from inner-edge to inner-edge. The velocity–time integral of blood flow was measured in the left ventricular outflow track by pulsed doppler. Mean transaortic gradient and maximal velocity were evaluated by transprosthetic continuous wave doppler. The doppler velocity index was calculated as the ratio of the proximal peak flow velocity in the LVOT to the transprothetic peak flow velocity. All examinations were interpreted blindly on a dedicated workstation (EchoPac 204 GE Healthcare) by two operators. In addition, during the follow-up, in case of bioprosthetic valve failure (BVF), a TEE and a cardiac CT were performed.

Study outcomes

The endpoints used were those proposed by the Valve Academic Research Consortium 3 (VARC3).

Mortality [ 8 ]

• Periprocedural mortality was defined as all-cause mortality occurring ≤ 30 days after the index procedure or occurring > 30 days but during the index hospitalization.
• Early mortality was defined as death occurring > 30 days but ≤ 1 year after the index hospitalization.
• Midterm mortality was defined as death occurring > 1 year after the index hospitalization but ≤ 4 years, at end of follow up.

Aortic bioprosthetic valve dysfunction (BVD)

• In terms of etiology, BVDs were defined as structural valve deterioration (SVD), nonstructural valve dysfunction (NSVD), thrombosis or endocarditis. SVD was reported as intrinsic permanent changes of the prosthetic valve [ 9 ]. NSVD was reported as any abnormality not intrinsic to the bioprosthesis, resulting in its malfunction (e.g. pannus, prosthesis-patient mismatch) [ 9 ].
• Hemodynamic valve performance assessment was protocolized at 1 year of the index procedure. Moderate hemodynamic valvular deterioration (HVD) was defined as an increase in the transaortic mean gradient of ≥ 10 mmHg resulting in a mean gradient of ≥ 20 mmHg, with concomitant decrease in the EOA ≥ 0.3 cm 2 and decrease in doppler velocity index ≥ 0.1 compared to the post-operative assessment. Severe HVD was defined as an increase in the mean gradient of ≥ 20 mmHg resulting in a mean gradient of ≥ 30 mmHg, with concomitant decrease in the EOA ≥ 0.6 cm 2 and decrease in doppler velocity index ≥ 0.2 [ 9 ].
• During the follow-up, the occurrence of a BVF was considered as an endpoint. Finally, BVF was defined by the occurrence of BVD associated with clinically expressive criteria (heart failure symptoms, fever, angina, ischemic event), irreversible severe HVD, aortic valve reoperation or re-intervention or valve-related death [ 9 ].

Statistical analysis

Continuous variables were expressed as means ± standard deviation or as medians with interquartile ranges (IQR) when not normally distributed. Nominal variables were expressed as numbers and percentages. The association between the mean values of continuous variables was assessed using the Mann–Whitney rank sum test. Nominal variables were investigated by the χ 2 test or the Fisher exact test when appropriate. The software XLSTATS v2019.1 (Addinsoft, Paris, FR) was used for statistical analysis.

This study included 91 patients, mostly men (74%) with a mean age at intervention of 70 ± 10 years. Preoperative patient’s characteristics are reported in Table ​ Table1. 1 . Most patients had an ascending aortic aneurysm (n = 65, 72%). There were 22 cases of redo procedures (24%). Sixteen procedures were performed on an emergency basis (18%), including 10 cases of type A acute aortic dissection (11%), 12 cases of severe prosthetic endocarditis (13%) and 1 complex of native aorto-mitral endocarditis. Forty-four patients underwent combined interventions (48%): coronary artery bypass graft in 22 cases (24%), mitral valve repair or replacement in 5 (6%) and aortic arch or hemiarch replacement in 14 (15.3%) cases.

Patients and intra-operative characteristics (n = 91)

AF—atrial fibrillation, CABG—coronary artery bypass graft; CPB—cardiopulmonary by-pass, GFR—Glomerular filtration rate, NYHA—New York Heart Association

Among the 83 patients discharged from hospital, 9 were lost to follow-up (10%). Median follow-up was 4 years.

The periprocedural mortality rate was 8% (n = 8). Among them, 3 patients with a pre-operative severe left ventricular dysfunction died shortly after the procedure from low cardiac output and multiorgan failure syndrome, 2 patients operated for complicated infective endocarditis on previous Bentall prosthesis died in the first 24 h from refractory septic vasoplegic syndrome, 2 patients operated for acute type A aortic dissection died either from massive hemorrhagic stroke or acute right ventricular failure in the first week after surgery and 1 patient experienced acute respiratory distress syndrome.

Early mortality rate was 2%. Among the 83 patients discharged from hospital, 2 died in the first year, both of them experiencing graft proximal anastomosis partial detachment at 9 and 10 months, respectively. Both were reoperated, but died from hemorrhagic stroke or massive intraoperative bleeding, respectively.

Midterm mortality rate was 4% (3 patients). One 62 years-old male, who had already undergone two Bentall procedures presented a recurrent bacterial graft endocarditis at 18 months after discharge. He was referred to surgery and died in the operating room from uncontrolled bleeding. One 83 years-old patient died from respiratory distress related to a severe form of Covid-19 pneumonia. The third, 72 years-old male died from metastatic pulmonary adenocarcinoma.

Bioprosthetic valve dysfunction

Early results.

Regarding the prosthetic hemodynamic features, despite normal postoperative hemodynamic profiles, without signs of obstruction, we observed a decrease in graft performance at 1 year, mainly in terms of EOA (1.3 ± 0.2 cm 2 vs 0.9 ± 0.4 cm 2 , p = 0.02 for 23 mm graft, 1.6 ± 0.4 cm 2 vs 1.2 ± 0.5 cm 2 , p = 0.01 for 25 mm graft, 1.9 ± 0.5 cm 2 vs 1.5 ± 0.5 cm 2 , p < 0.01 for 27 mm graft, 2.1 ± 0.6 cm 2 vs 1.6 ± 0.6 cm 2 , p = 0.17 for 29 mm graft) but also in terms of transaortic mean gradient and maximum velocity. [ 10 , 11 ].

At the 1-year follow-up, 10 patients fulfilled criteria for HVD (13%), 6 being moderate and 4 severe. The factors associated with HVD are presented in Table ​ Table2. 2 . Preoperative characteristics were not associated with HVD. The implanted graft caliber was significantly associated with the occurrence of HVD at 1 year (8 (80%) vs. 21 (33%), p  = 0.01 for 23- or 25-mm graft), especially in the smallest sizes.

Factors associated with the presence of hemodynamic valve deterioration (HVD) at 1 year (n = 74)

AF—atrial fibrillation, AHT—arterial hypertension, CABG—coronary artery bypass graft; CPB—cardiopulmonary by-pass, GFR—Glomerular filtration rate, HVD—hemodynamic valve deterioration; LVEF—left ventricular ejection fraction; Vmax—maximum velocity; Continuous variables were expressed as means ± standard deviation. Nominal variables were expressed as numbers and percentages in bold: p value ≤ 0.05

However, the patients who secondarily developed HVD had similar hemodynamic parameters as the rest of the cohort at the pre-discharge postoperative exam.

There was 1 case (1.3%) of early graft endocarditis with negative blood cultures, diagnosed at 8 months after surgery. We treated it medically.

We noted three cases (4.1%) of partial proximal anastomosis disruption: two cases with total atrio-ventricular disruption with large false aneurysms at the level of the proximal anastomosis at 9 months and respectively at 10 months after the initial surgery. We did not find any argument in favor of an infective endocarditis. Moreover, one patient’s initial surgery was in an elective setting, for a degenerative aortic aneurysm. The third patient had a similar aortic root disruption, but it appeared 4 months after a Bentall intervention for a complex aortic and mitral endocarditis with fragile tissues.

Midterm results

Five patients experienced infective endocarditis (6.8%) at a median of 1 year and 4 months. One patient was treated surgically and the other 5, medically.

There weren’t observed any more cases of hemodynamic dysfunction or AV disruptions until follow up was closed.

Regarding early and midterm results, we observed a total of 14 patients presenting a BVF during follow-up (17%). A re-intervention was performed in 8 cases (10%). Three patients had a valve-in-valve TAVR for severe HVD. Five patients had open redo surgery: three cases of partial proximal anastomosis detachment, one case of graft endocarditis with valvular involvement and one severe HVD. Among them, 3 patients died related to the procedure.

Regarding etiologies of BVF, 6 patients experienced infective endocarditis (8%), 3 patients had partial proximal anastomosis detachment (4%) and the other 4 patients had severe irreversible HVD (5.5%). All patients with endocarditis underwent TTE and TEE which were abnormal in two cases, highlighting valve involvement (aortic vegetations (n = 2), aortomitral abscess (n = 1) and pseudoaneurysm (n = 1)). Endocarditis patients also underwent a CT scan which showed in all cases a proximal collection around the biological graft with peripheral contrast diffusion, without signs of a pseudoaneurysm. PET combined with CT (PET/CT) was also performed in four cases, showing an abnormal intense uptake on the graft collection and/or the valvular prosthesis. Regarding the pathogens involved, there were 2 cases of staphylococcus involvement (aureus and epidermidis), 1 with Enterobacter Aerogenes, 1 with E. coli, another case a streptococcus oralis infection and lastly, 1 with negative blood cultures.

For all patients with HVD, thrombosis was ruled out by CT, and endocarditis by Duke criteria. SVD was eliminated by TEE and CT. Of note, none of these patients had regurgitation. Regarding NSVD, a patients-prosthesis mismatch did not appear to be involved, as postoperative indexed EOA was not associated with the occurrence of HVD at 1 year. Finally, for all patients with HVD, imaging found a 3–4 mm, circumferential, hyperechogenic ring, located at the level of the prosthetic aortic annulus and at the graft’s proximal anastomosis towards its’ ventricular side, near the pledgets. In these patients, on CT and TEE, there was no structural prosthetic abnormality (neither fibrosis, calcification, leaflet tear and wear, hypo-attenuated leaflet thickening nor thrombosis). Moreover, we have randomly reviewed patients’ echocardiographic exams concluding that the circumferential structure is a common finding in patients being implanted with this type of biological graft. Indeed, 29 patients had a reduction of their aortic annulus size at 1 year (39%). We identified this annular structure in the per-operatory setting, during the reintervention for a failing bioprosthesis (Fig.  1 ).

A Transesophageal echocardiography, deep transgastric view, annular hyperechogenic structure (yellow arrow); LVOT—left ventricle outflow tract; B Intraoperative view with the annular diaphragmatic structure (black arrow) visualized after complete prosthetic dissection

This prospective study reports the midterm outcomes of 91 consecutive patients who underwent a Bentall procedure with the BioConduit™ No React® between 2017 and 2020, in our institution. Main results are as follows: 1) the hemodynamic performances at 1 year were unsatisfying, with an overall trend towards reduction in EOA and a significant rate of HVD, 2) despite the No-react® treatment of the conduit, graft endocarditis was not rare and 3) we observed some cases of early graft detachment at its proximal anastomosis with the aortic root.

Biological bioconduits, by avoiding stent and sewing cuff at the annular level, are intended to achieve more physiological flow pattern and thus superior hemodynamics [ 7 , 12 , 13 ]. However, our study identified a high rate of HVD and a general decrease in EOA at 1 year as being related to prosthesis of smaller calibers (23 and 25 mm) ( p  < 0.001) and renal insufficiency ( p  < 0.001) (Table ​ (Table2). 2 ). Even though we observed a general reduction in the annulus diameter, we think it had a more rapid obstructive impact in initially smaller calibers.

Regarding patients with HVD, our imaging protocol allowed us to rule out endocarditis, thrombosis or SVD in all cases. Our main observation explaining this phenomenon causing NSVD might be similar to a pannus formation. Firstly, we noticed a reduction in the aortic annulus diameter at 1 year (Fig.  2 ). In addition, we found a 3–4 mm, external circumferential, hyperechogenic, non-perfused ring, situated at the level of the prosthetic aortic annulus and at the graft’s proximal anastomosis near the pledgets. This structure was identified during our imaging protocol and confirmed in the perioperative setting (Fig.  1 ). We concluded that HVD was probably related to the external circumferential diaphragm that explained the shrinkage of the aortic diameter. Nevertheless, it is interesting to notice the rapid development of this “pannus-like” structure, in less than a year (Additional files 1 , 2 , 3 ). Concerning its potential cause, several hypotheses are put forward. It may be related to the surgical techniques as the structure was near the pledgets used for our surgical interrupted suture, reinforced with biological fibrin glue.

Transthoracic echocardiography, long axis parasternal view with same patient early post-operatory ( A ) and ( C ) and 1-year follow up exam ( B ) and ( D ), showing a shrinkage of the aortic annulus at 1 year (measured at the level of the yellow arrows), from 18 to 14 mm ( A ) and ( C ) together with a transaortic mean gradient and maximal velocity by Doppler continuous wave interrogation, from 2,4 m/sec and 12 mmHg ( B ) to 4,6 m/sec and 59 mmHg ( D )

As for the surgical implantation technique, we used either a multiple, single, interrupted, non-everting, pledged reinforced U-stiches to implant the composite graft in supra-annular position (n = 33, 36%) or everting stitches to implant the prosthesis in intra-annular position (n = 58, 64%). After univariate analysis, we found no correlation between the technique and the event of bioprosthetic valve dysfunction (Table ​ (Table2, 2 , p  = 0.47).

We can also consider the role of the immune system. The glutaraldehyde bioconduit treatment is meant to eliminate immunogenic proteins [ 14 ]. Nevertheless, multiple observational studies identified xenograft porcine components (extracellular matrix specific glycans, galactose-a-1,3-galactose and N-glycolylneuraminic acid) who trigger host antibody formation [ 15 – 19 ]. Sustaining the same immunogenic hypothesis, a group from Munich studied the effects of a pericardial porcine, No-React® patch and they found sterile abscess formation that was suspected to be an immunogenic reaction, a xenogeneic complement-mediated graft rejection [ 20 ]. The question of patient-prosthesis mismatch can be raised because the smallest sizes of prostheses seemed to be more sensitive to hemodynamic deterioration. We believe that this observation is not related to an initial mismatch but to the fact that a decrease in EOA logically has more impact on a small prosthesis than on a larger one.

In light of all of the above, we speculate an early inflammatory reaction could have been triggered by the biological conduit itself, favored by the use of biological glue or/and by the surgical technique (all patients were implanted using a multiple, single, interrupted, everting or non-everting suture with pledged reinforced U-stiches). Lastly, concerning the surgical technique, we note that other teams (Carrel et al., Stefanelli et al., Sahin et al., Kaya et al., Galinanes et al.) reported using as technique of conduit implantation either a running suture or an interrupted, nevertheless, they were not confronted with this problem [ 13 , 21 – 24 ].

Six patients were diagnosed with graft endocarditis. Diagnosis was made according to the modified Duke criteria and was often difficult, due to a combination of atypical clinical, biological, radiological and echocardiographic observations [ 25 ]. These features are not specific to this conduit and are usual after Bentall surgery. These results are surprising insofar as one of the advantages put forward in favor of these conduits is their expected low rate of reinfection.

In this regard, Galinanes et al. reported excellent late results (1 case of conduit infective endocarditis in 10 years) [ 13 ]. Siniawski et al., Musci et al. and Wendt et al. suggested the same reassuring results [ 26 , 27 , 31 ]. Recently, Stefanelli et al. also reported satisfactory results, with freedom from the BioConduit® graft infection of 95.7% at 5 and 15 years (CI 0.95) [ 22 ]. However, larger cohorts are still needed to confirm these results.

Previous studies reported a high number of aorto-ventricular disconnections especially related to the initial Shelhigh’s biological conduit [ 21 , 23 , 24 , 28 ]. The Shelhigh graft was a stentless, valved, No-React® biological conduit implanted mostly in the early 2000s. Due to unexpected conduit disconnections, in 2007, the United States FDA published a notification, the product being retried of the market [ 28 , 30 ]. Despite this drawback, in 2013, Musci et al. published reassuring results after 11 years of follow-up of 255 patients implanted with Shelhigh initial graft [ 30 ]. The Berlin group reported a low reinfection rate (0.78% early and 2.35% late reinfection) concluding that patients’ outcome was dependent of their surgical urgency. Afterwards, a new version of the graft, the BioIntegral Surgical, BioConduit™ was released on the market. Regarding its predecessor (the Shelhigh conduit), while some teams report relatively satisfactory early and late follow-up results (Galinanes et al., Musci et al.), other teams report some dreadful complications (Sahin et al., Kaya et al., Carrel et al., Reineke et al., Sadeque et al.) referring to the high rate of endocarditis and of atrio-ventricular disconnections with proximal false aneurysm formation [ 13 , 21 , 23 , 24 , 27 – 30 , 32 ]. In contrast, they report conduit hemodynamic dysfunction only in a few cases. Reineke et al. describes 8 cases (2.3%) with structural valve deterioration at late follow up. In contrast, Kaya et al. reports 3 cases (1.7%) with hemodynamic failure at early follow-up, without detailing. Concerning the BioConduit™, Stefanelli et at publishes satisfactory early and long-term results [ 22 ]. In our series, we report 10 cases (13%) presenting criteria for non-structural hemodynamic valve dysfunction at 1 year and 4 of them fulfilling criteria for failure, needing reintervention. This was an unexpected finding, as to our knowledge, such a high incidence of biological conduit hemodynamic dysfunction was never cited before.

There are several limitations of this study. This was a prospective but single-center, non-randomized study with lack of group control. Even though there were 91 patients included, the population analyzed was rather small and heterogenous, gathering elective as well as emergent cases. Being a single institution study, with 4 surgeons and 2 techniques, while representing a limitation, could contribute to reducing biases related to the use of multiple techniques.

This study reports the early and midterm results of the newest all-biological valved conduit. Even though it is designed to achieve superior hemodynamics by excluding the valvular stent, our study reveals an abnormally high rate of early prosthetic non-structural dysfunction and failure that appears to be mostly related to a multifactorial progressive shrinkage of the aortic annulus. Regarding graft infections, we observed that endocarditis is not rare, despite conduits all-biological structure. Lastly, there are still some cases of conduit proximal anastomotic detachments.

Acknowledgements

Not applicable.

Abbreviations

Author contributions.

The corresponding author (RB) and YL-B conceived and designed the analysis. AG collected data and conceived the tables. YL-B performed the statistical analysis. All authors discussed the results and contributed to the final manuscript. The corresponding author and JP wrote the paper. All authors read and approved the final manuscript.

This research has received no external funding so there is no funding body to acknowledge.

Availability of data and materials

Declarations.

The prospective, observational study was performed in accordance with the principles outlined in the Declaration of Helsinki and it was approved by the Institutional Review Board of the Rangueil University Hospital of Toulouse, France (number RnlPH 2022-50). Informed consent to participate in the study was obtained from participants. Patients were informed that their codified data would be used for the study.

Participants have given written consent to publishing research findings.

None of the authors have any conflict of interest to declare.

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