Modified Bentall Procedure with Composite Biologic Grafts

Abstract

The search continues for the ideal composite biologic graft (CBG). We have performed aortic root replacements with CBGs, initially with a stented pericardial valve in a Valsalva graft (Gen1) and subsequently with the stentless 3f valve (Gen2). The valve is sewn at the base of the graft sinuses, leaving residual proximal graft to sew separately to the left ventricular outflow tract. This allows for CBG size standardization and permits fabrication prior to bypass. We share our institutional experience and aim to show noninferiority of this technique, as well as discuss potential advantages. The first 75 patients to receive each generation of CBG were identified and assessed retrospectively. Overall survival was assessed as our primary outcome. Various secondary outcomes were also analyzed, including operative times and short-term outcomes. Operative times were shorter for Gen2, with cardiopulmonary bypass times that were significantly reduced (126.3 ± 5.2 minutes vs. 157.6 ± 5.8 minutes for Gen1, p = 0.001) and aortic cross-clamp times that trended lower (98.2 ± 4.2 minutes vs. 107.7 ± 3.8 minutes for Gen1, p = 0.095). There were no postoperative myocardial infarctions (MIs) or aortic insufficiency graded 2+ or greater in either group. There was only one stroke in a Gen1 patient who recovered fully. Kaplan-Meier survival analysis showed a strong trend toward improved survival among Gen2 patients (p = 0.0566). Our experience with Gen2 CBG showed decreased operative times and a trend toward improved survival, though further patient follow-up and larger sample sizes in prospective studies are necessary. Further research with this CBG and additional improvements are warranted.