Bentall-De Bono Procedure Research Articles

The Frozen Elephant Trunk Procedure Using New Russian Hybrid Prosthesis "Soft Elephant Trunk": the Early Experience.

Aim To present the first experience of performing the Frozen Elephant Trunk (FET) surgery in patients with thoracic aorta disease using a new Russian hybrid stent graft "Soft Elephant Trunk".Material and methods Between 2014 and 2021, 170 patients with thoracic aortic disease underwent complete aortic arch replacement using the FET technique. In 70 of these cases (since June 2019), a hybrid graft "Soft Elephant Trunk" was used. A specific feature of this graft is the conical reduction of the radial force of nitinol crowns and the soft distal end without radial force. The study endpoints were early postoperative results, as well as the absence of reoperations on the aorta, absence of stent-graft-associated complications, including distal stent-graft-induced fenestration, and survival at a mid-term follow-up of up to 2.5 years.Results Interventions were performed in patients with A type aortic dissection (n=51; 72.9 %), type B aortic dissection (n=13; 18.6 %), and thoracoabdominal aortic aneurysm (TAAA) (n=6; 8.5 %). In 14 (20 %) of these cases, interventions were performed after a primary intervention on the proximal aorta. Acute aortic dissection was diagnosed in 17 (24.3 %) cases. Aortic root replacement was performed in 21 (30 %) cases, David procedure in 5 (7.2 %) cases, Bentall-DeBono procedure in 11 (15.7 %) cases, and supracoronary graft placement in 33 (47.1 %) cases. There were no cases of paraplegia or paraparesis. Respiratory insufficiency was observed in 8 (11.4%) cases. In one (1.4%) case, acute renal failure developed, which required renal replacement therapy. In-hospital mortality was 4.3 % (3 patients died). Mean follow-up duration was 9 [4.25; 16] months. Three-year survival was 94 % (95 % confidence interval, CI: 88-99.9) and absence of reoperation was 96.6 % (95 % CI: 90.1-100). There were no cases of distal stent-graft-induced fenestration in this group.Conclusion The new hybrid graft, due to its specific structure, provides prevention of distal stent-graft-induced fenestration and, thereby, a stable long-term result. Using this stent-graft is effective in patients with thoracic aorta pathology undergoing the FET surgery. However, further studies are needed to determine potential advantages and disadvantages of this new hybrid graft, to obtain long-term results and accumulate experience.

Aortic valve replacement using a polytetrafluoroethylene leaflet valve in patients with a history of the Bentall–De Bono procedure: a case series

Objective: To analyze outcomes of 4 transcatheter aortic valve replacements using a polytetrafluoroethylene leaflet valve in patients with a history of the Bentall–De Bono procedure.Methods: We retrospectively analyzed a series of 4 cases. From February 2019 to March 2022 in Federal Center for Cardiovascular Surgery (Penza, Russia), patients with a history of the Bentall–De Bono procedure underwent transaortic aortic valve implantation of the MedLAB-CT balloon-expandable valve under cardiopulmonary bypass and cardioplegia. Valve No. 25 was implanted in 3 patients, and 1 patient received valve No. 23.Results: According to echocardiography, valve hemodynamic performance improved in the postoperative period: mean and peak pressure gradients were 11.5 and 24 mm Hg, respectively; the median value of effective orifice area was 1.9 cm2, while mitral regurgitation in all cases did not exceed grade 1. Median cardiopulmonary bypass and myocardial ischemia times were 59 and 31 minutes, respectively. There was no immediate and remote mortality. No complications were reported in the postoperative period.Conclusion: The proposed replacement of the valved conduit’s compromised part after the Bentall–De Bono procedure can significantly reduce the extent of surgery, cardiopulmonary bypass and myocardial ischemia times, as well as simplify the procedure. Received 1 December 2022. Revised 10 February 2023. Accepted 16 February 2023. Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interests: The authors declare no conflict of interest. Contribution of the authorsLiterature review: V.A. Karnakhin, I.D. PotopalskiyDrafting the article: V.V. Bazylev, A.B. Voevodin, I.D. Potopalskiy, V.A. KarnakhinCritical revision of the article: A.A. Kuznetsova, M.P. PatelSurgical treatment: V.V. Bazylev, A.B. VoevodinFinal approval of the version to be published: V.V. Bazylev, A.B. Voevodin, I.D. Potopalskiy, V.A. Karnakhin, M.P. Patel, A.A. Kuznetsova

Aortic Root Surgery in Adults: An Unsolved Problem

Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.

Mid-term outcomes of an alternative remodelling technique for aortic root replacement without coronary ostial mobilisation or reimplantation

BackgroundWe compare the early and late outcomes of a modified aortic root remodelling (ARR) technique for aortic root replacement without mobilisation or reimplantation of the coronary ostia, with those of the modified Bentall-de Bono procedure.MethodsA retrospective observational study was performed comprising 181 consecutive patients who underwent aortic root replacement with a modified Bentall-de Bono procedure (104 patients) or ARR (77 patients) between January 2013 and December 2019. Primary endpoints included hospital mortality and late survival. Secondary endpoints included incidence of post-operative complications and freedom from late re-operation.ResultsARR procedures were performed with shorter cross-clamp times and comparable cardiopulmonary bypass times to modified Bentall-de Bono procedures. The incidence of early post-complications was comparable between groups. 30-day mortality was numerically lower with ARR than the modified Bentall-de Bono procedure. Over 7-year follow-up, 4 patients (3.8%) required repeat aortic surgery after a modified Bentall-de Bono procedure, and none after ARR. Long-term mortality after ARR and after modified Bentall-de Bono procedures was 17.1% and 22.7%, respectively. The cumulative incidence of reintervention on the aortic root/valve was 3.2% after a modified Bentall-de Bono procedure and 0% after ARR. When adjusted for other independent risk factors, late mortality was not influenced by the procedure performed, although competing risk adjusted for age showed that the modified Bentall-de Bono procedure was associated with an increased risk of aortic root/aortic valve re-operation.ConclusionsThe modified ARR technique is associated with reduced myocardial ischaemia time, lower post-operative mortality and aortic re-intervention rates compared to a modified Bentall-de Bono procedure. It may be considered a safe and feasible procedure for aortic root/ascending aortic replacement offering good long-term outcomes.

Bentall-DeBono procedure with semistented tissue aortic valve prosthesis

Bentall-DeBono procedure with semistented tissue aortic valve prosthesis

Aortic homograft for valved conduit infection in a patient with severe heart failure after previous Bentall—De Bono procedure

Aortic homograft for valved conduit infection in a patient with severe heart failure after previous Bentall—De Bono procedure

Aortic surgery in a patient with Marfan's syndrome and pectus excavatum (shoemaker's chest)

Patients with Marfan syndrome often have severe life-threatening cardiovascular complications, including aortic aneurysmal dilatation or aortic dissection. Approximately two-thirds of people who have this syndrome suffer from chest wall deformities such as pectus excavatum (cobbler's chest) or pectus carinatum (bird's chest). When a patient with cobbler's chest requires aortic root surgery, the operator may face a major clinical challenge in selecting the optimal surgical access and approach. We present a case of a patient with Marfan syndrome and severe pectus excavatum who underwent aortic valve replacement, aortic root and ascending aorta reconstruction, coronary artery reimplantation (Bentall de Bono procedure ) via upper partial L-sternotomy and anterior left thoracotomy.

Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population.

Background: Aortic valve and root replacement (AVRR) is a standardised procedure to treat patients with aortic valve and root disease. In centres with a well-established aortic valve and root repair program (valve repairs and Ross operations), only patients with very complex conditions receive AVRR; this procedure uses a mechanical or biological composite valve graft (modified Bentall–de Bono procedure). The aim of the study was to evaluate the short- and long-term results after AVRR in a high-risk population with complex pathologies. Methods: Between 2005 and 2018, a total of 273 consecutive patients (mean age 64 ± 12.8 years; 23% female) received AVRR. The indication for surgery was an acute type A aortic dissection in 18%, infective endocarditis in 36% and other pathologies in 46% patients; 39% were redo procedures. The median EuroSCORE II was 11.65% (range 1.48–95.63%). Concomitant surgery was required in 157 patients (58%). Results: The follow-up extended to 5.2 years (range 0.1–15 years) and it was complete in 96% of the patients. The 30-day mortality was 17%. The overall estimated survival at 5 and 10 years was 65% ± 3% and 49% ± 4%, respectively. Univariate and multivariate logistic regression analyses revealed the following risk factors for survival: perioperative neurological dysfunction (OR 5.45), peripheral artery disease (OR 4.4) and re-exploration for bleeding (OR 3.37). Conclusions: AVRR can be performed with acceptable short- and long-term results in a sick patient population. The Bentall–De Bono procedure may be determined to be suitable for only elderly or high-risk patients. Any other patients should receive an AV repair or the Ross procedure in well-established centres.

P43 CARDIAC SURGERY IN PATIENTS WITH MARFAN SYNDROME: 20–YEAR SINGLE–CENTER EXPERIENCE

Abstract Marfan syndrome is a connective tissue disease whose most fearsome complications are proximal thoracic aorta enlargement and dissection. Nonetheless, cardiac surgery has proven to be able to considerably extend average life expectancy up to approximately 70 years1. The aim of our study was to analyze which procedures had been performed on these patients. From 2000 to 2020 we retrospectively enrolled 89 consecutive patients undergoing a first–time surgical operation at our department. Overall, aortic root surgery represented the most frequent procedure (82 patients, 92.2%), with valve–sparing operation being the preferred one (53 patients, 59.6%). On the other hand, 29 patients (32.6%) underwent Bentall–De Bono procedure. Consequently, we compared these 2 groups of patients. In emergent operation, typically type A aortic dissection, Bentall–De Bono procedure was preferred in almost all cases (p–value 0.031). Few patients required the replacement of part or all of the arch, respectively 3 and 6, with no statistical difference between the two groups. However, while 2 valve–sparing patients required a mitral valve repair, 8 patients who underwent aortic root replacement had also their mitral valve replaced. Considering mean age (average 34.68 years), predictably almost all Bentall–De Bono patients had both their aortic and mitral valve replaced with a mechanical prosthesis (respectively 27 and 7 out of 29 and 8). Although there was no significant difference, replacement of the aortic root with a composite graft required less cross–clamp time, being also different the complexity of the technique. ICU stay was significantly different, since patients who had their aortic valve spared needed intensive assistance for an average of just 1.57 days, while the other group for 6.03 days (p–value 0.037). Similarly, but non significantly, hospital stay differed (13.91 and 18.17 days). Only 2 patients died during hospital recovery, both part of the Bentall–De Bono group (p–value 0.055). During the follow–up period (average 89.39 months), 6 patients died, 2 of them for noncardiac related causes, and 9 (11.3%) required another operation. In conclusion, Marfan syndrome is characterized by a dangerous proximal aorta involvement, which in some cases may be life–threatening if left untreated. Fortunately, surgery has significantly improved life quality and expectancy of these patients, who must be adequately diagnosed and then monitored by their referral centers.

Aortic valve reimplantation in patients with Marfan and other connective tissue syndromes: a success story for these patients!

After the introduction of aortic valve (AV) and root replacement (Bentall–De Bono procedure), survival changed dramatically for patients with AV and/or root pathologies, including patients with Marfan syndrome or other genetic connective tissue diseases (CTD) [1, 2]. Since the latter mentioned patients are presented for surgery at a very young age, mechanical prosthesis is generally chosen over the biological. The consequent need for life-long anticoagulation exposes the patients to the potential, sometimes severe complications accounting up to 5% per year [3]. Due to this fact, AV-sparing techniques have been evolving over the last 30 years. Especially, AV reimplantation, as described by David and Feindel in 1992, became the standard technique for valve-sparing aortic root replacement with excellent short- and long-term results, even in patients with Marfan syndrome or other CTD [2, 4, 5]. In this issue of the European Journal of Cardiothoracic Surgery, Gil et al. describe their experience with AV reimplantation (David operation) in 157 patients with Marfan syndrome (143 patients) and other CTD [6]. The presented cohort is one of the largest published yet. The early- and long-term outcomes (median of 7.3 years) are impressively good. Especially, survival at 10 and 15 years with 98% is excellent and not different to the general Spanish population for the same age and gender. Furthermore, reported freedom from greater than moderate aortic regurgitation and reintervention were 90% and 96% at 10 years, respectively. Importantly, all these patients were operated by the same cardiosurgical team. The clear message that can be derived from this article is that David operation is an excellent option for the surgical treatment of these patients. The authors also conclude these patients should be centralized in referral centres and operated by very experienced surgeons. Finally, based on these results, authors postulate the threshold for prophylactic surgery in CTD should be reviewed and lowered.

Contained rupture of a sinus of Valsalva aneurysm: Is it just a matter of luck?

BackgroundContained rupture of the ascending aorta is a rare condition, but the severity of this complication enforces strict guidelines for its prevention and a prompt diagnosis, once already occurred.Case presentationA 66-year-old man with a history of type 2 diabetes, longstanding aortic valve stenosis and aortic root aneurysm of 47 mm was hospital admitted for elective surgery. A Bentall-De Bono procedure was performed in order to replace the stenotic bicuspid aortic valve and exclude the dilated portion of the aortic wall. Intraoperatively, a discontinuity of the aortic wall, just above the aortic annulus, at the non-coronary sinus of Valsalva was incidentally observed. The aortic wall discontinuity was none other than a contained aortic rupture. The preoperative CT-scan images were afterwards analyzed by the radiologist, in order to identify the contained aortic rupture. Indeed a false aneurysm of the non-coronary sinus of Valsalva of a maximum diameter of 15 mm was detected, thanks to a 3D reconstruction.ConclusionsThe diagnosis of contained aortic rupture is certainly demanding, particularly in absence of signs or symptoms of rupture in a chamber of the heart or in the pericardium. Although this case represents a consensus of experts’ opinion, the recognition of these specific cases in which the risk of dissection, rupture or death is at its highest, would allow to operate at the appropriate time, improving the outcomes.

Bentall–De Bono procedure for aortic regurgitation and intraoperative rupture of moderately dilated ascending aorta: A case report

We herein present a clinical case of root and ascending aortic replacement in a patient with borderline enlargement of the ascending aorta and aortic valve insufficiency. A 65-year-old man was admitted to our clinic with signs of heart failure. Subsequent echocardiography and contrast-enhanced computed tomography revealed hemodynamically significant aortic insufficiency, as well as expansion of the ascending aorta. Diameter at the levels of the sinuses of Valsalva, sinotubular junction and tubular portion of the ascending aorta were 48, 47 and 44 mm, respectively. Based on the aforementioned data, indications for isolated aortic valve replacement were determined. Although the main portion of the surgery was unremarkable, at its final stage, a rupture of a section of the ascending aorta occurred. The results of intraoperative express histological examination of the enlarged aorta revealed connective tissue dysplasia and cystic median necrosis. Replacement of the ascending aorta was performed using the modified Bentall–De Bono technique. This case demonstrated that a borderline aortic dilatation of 40–50 mm at the ascending aorta was associated with pathological changes in its wall, which can cause fatal complications (rupture and dissection) and may require a more aggressive approach during surgical correction. Intraoperative express histological examination of the wall of the ascending aorta in ambiguous situations can help determine the scope of the intervention.Received 16 March 2021. Revised 14 September 2021. Accepted 15 September 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflict of interest.Contribution of the authors Literature review: S.Yu. Boldyrev, M.A. Marukyan Drafting the article: S.Yu. Boldyrev, M.A. Marukyan, V.N. Suslova Critical revision of the article: S.Yu. Boldyrev, V.A. Porkhanov Surgical treatment: S.Yu. Boldyrev, M.A. Marukyan Final approval of the version to be published: S.Yu. Boldyrev, M.A. Marukyan, V.N. Suslova, K.O. Barbukhatti, V.A. Porkhanov

Observe the Unexpected: A Strange History of Bioprosthesis in a Patient in Dialytic Treatment

A 73-year-old male with a history of right nephrectomy due to cancer in 1996 was referred to our hospital for dyspnea and acute chest pain. In May 2007, the Shelhigh® No-React® valved bioconduit was implanted using the Bentall-De Bono procedure due to the finding of severe aortic valve insufficiency and acute type A aortic dissection. Nine months after discharge, he was placed on chronic renal dialysis. The patient’s condition was followed carefully after being placed on dialysis, and now, thirteen years later the implanted aortic valve is still moving freely without signs of calcification.

Endovascular Thoracoabdominal Replacement after Total Abdominal Aortic Debranching.

Marfan syndrome is an inherited connective tissue disorder affecting mainly eyes and skeletal and cardiovascular systems. Cardiovascular involvement may lead to life-threatening aortic pathologies including aneurysms and/or dissections. In this report, the authors present images of a patient with Marfan syndrome with a history of Bentall-De Bono procedure followed by aortic arch and infrarenal aortoiliac replacements who strongly refused conventional open repair and underwent abdominal debranching followed by thoracoabdominal endovascular stent grafting for the treatment of thoracoabdominal aneurysm.

Complete aortic prosthetic valve dehiscence after modified Bentall-De Bono procedure

A 56-year-old male patient was admitted to our clinic due to persistent fever despite the use of antibiotics for 2 weeks, chest pain, and presyncope. His medical history revealed that the patient underwent modified Bentall-De Bono procedure 2 months ago due to ascending aortic aneurysm and severe aortic insufficiency. Transthoracic apical 5 chamber view showed that mobile vegetation prolapsed into the left ventricular outflow tract during ventricular diastole and that mechanical prosthetic valve was superior to the aortic annulus. Transesophageal echocardiography revealed normal aortic mechanical prosthetic valve function; however, the valve was positioned more superior to the annular plane and a dense vegetation was observed. Moreover, a complete dehiscence of the prosthetic valve was attached to aortic annulus with a single stitch in an area between noncoronary sinus and left coronary sinus. Dense thrombus formation was observed in the perivalvular region. Many cases with prosthetic valve endocarditis and partial dehiscence as its complication have been reported in the literature. However, to the best of our knowledge, there is no reported case of complete dehiscence secondary to infective endocarditis following complete ascending aortic graft and prosthetic aortic valve replacement (modified Bentall-De Bono procedure).

Massive Bleeding After Median Sternotomy: Case Report of an Infrequent Complication of Infective Endocarditis

bstract We report an unusual complication of acute infective endocarditis, found in a 70 year-old man with a previous history of two cardiac surgery procedures. The first one was a full root replacement (BentallDe Bono procedure), associated with three bypasses (one mammary and two vein grafts). The second procedure was a mitral valve replacement through a right thoracotomy ought to native mitral valve endocarditis. In the current admission, echocardiography showed a periaortic abscess (Figure 1) and severe prosthetic mitral valve insufficiency. CT scan showed a big collection in the anterior mediastinal space adjacent to the composite graft (Figure 2), which was suspected to be purulent material. A third surgical intervention was programmed despite the extreme surgical risk. During the median sternotomy, a massive bleeding occurred. It was originated in the mediastinal collection, which truly was a collection of contained bleeding, originated in the 10 yearsold anastomosis of the saphenous vein to the composite graft, which was completely detached due to endocarditic involvement of the aortic graft. The institution of cardiopulmonary bypass before sternal opening enabled the surgical team to maintain a stable hemodynamic situation and to continue the procedure satisfactorily. You can submit your Manuscripts at: https://symbiosisonlinepublishing.com/submitManuscript.php

Mini-Bentall: An Interesting Approach for Selected Patients.

Minimally invasive surgery through an upper hemisternotomy for aortic valve replacement has become the routine approach with excellent results. Actually, the same minimally invasive access is used for complex ascending aorta procedures only in few centers. We report our experience with minimally invasive approach for aortic valve and ascending aorta replacement using Bentall technique. From January 2010 to November 2015, a total of 238 patients received ascending aorta and aortic valve replacement using Bentall De Bono procedure at our institution. Low- and intermediate-risk patients underwent elective surgery with a minimally invasive approach. The "J"-shaped partial upper sternotomy was performed through a 6-cm skin incision from the notch to the third right intercostal space. Patients who had previous cardiac surgery or affected by active endocarditis were excluded. The study included 53 patients, 44 male (83 %) with a median age of 63 years [interquartile range (IQR), 51-73 years]. A bicuspid aortic valve was diagnosed in 27 patients (51%). A biological Bentall using a pericardial Mitroflow or Crown bioprosthesis implanted in a Valsalva graft was performed in 49 patents. The remaining four patients were treated with a traditional mechanical conduit. Median cardiopulmonary bypass time and median cross-clamp time were respectively 84 (IQR, 75-103) minutes and 73 (IQR, 64-89) minutes. Hospital mortality was zero as well as 30-day mortality. Median intensive care unit and hospital stay were 1.9 and 8 days, respectively. The study population compared with patients treated with standard full sternotomy and similar preoperative characteristics showed similar results in terms of postoperative outcomes with a slightly superiority of minimally invasive group mainly regarding operative times, incidence of atrial fibrillation, and postoperative ventilation times. A partial upper sternotomy is considered a safe option for aortic valve replacement. Our experience confirms that a minimally invasive approach using a partial upper J-shaped sternotomy can be a safe alternative approach to the standard in selected patients presenting with complex aortic root pathology.

Redo Bentall-de Bono procedure after previous ascending aortic and aortic valve replacement

Redo Bentall-de Bono procedure after previous ascending aortic and aortic valve replacement

AORTITIS - A SILENT DISEASE AND SEVERE COMPLICATIONS

The article presents a clinical case of delayed diagnosis of extra-articular manifestations of ankylosing spondylitis and aortitis. 15 years after the onset of symptoms, this diagnosis was established when the irreversible joint damage and cardiovascular complications were present, namely extra-articular manufestatations of aortitis, i.e. ascending aortic extension and the total aortic insufficiency. This clinical case presents a successful surgical treatment of acquired aortic valve disease. The patient underwent the Bentall-de Bono procedure, including aortic valve replacement and plasty of the ascending aorta with a valved conduit “MedEng-23” (MedEng, Russia). Moreover, the current article highlights the problem of selecting optimal medical therapy (therapy for ankylosing spondylitis and anticoagulants) due to ad-verse drug interactions. The reasons for delayed diagnosis were analyzed. Unfortunately, the main reasons are subjec-tive, i.e. general physicians (non-rheumatologists) do not know well clinical signs and symptoms of this disease as well as imaging findings suggesting this diagnosis.

Concomitant bentall-de bono procedure plus total arch replacement and coronary artery bypass grafting in acute aortic dissection

We report the images of a case of a 31-year-old male presented with acute Type A aortic dissection with severe aortic regurgitation involving the arch vessels. He was taken up for surgery on cardiopulmonary bypass (femoro-axillary-bicaval). Bentall-De Bono procedure with mechanical aortic valved conduit and total arch replacement with woven polyester branched graft under hypothermic circulatory arrest plus selective antegrade cerebral perfusion was performed. Reversed saphenous venous graft to proximal right coronary artery grafting was also performed.