Success Story of Bentall Procedure for Aortic Root Replacement

The Bentall procedure is a surgical repair of the ascending aortic or aortic root aneurysm in combination with aortic valve disease. A 39-year-old female patient came to the hospital with symptoms of Shortness of breath and Chest pain. The 2D echo showed a bicuspid aortic valve with severe aortic stenosis and regurgitation, and moderate mitral regurgitation with fair left ventricular function. A Computed tomography aortogram showed abnormal dilation of the proximal aorta suggestive of a type II-A aortic aneurysm extending from the aortic root to the origin of the innominate artery. The ascending aorta was huge in size with mild cardiomegaly.

The aortic root, the annulus, and the Sino tubular junction were dilated with a heavily calcified bicuspid aortic valve followed by calcification of the annulus with concentric left ventricular hypertrophy. The bicuspid aortic valve was excised after thorough decalcification; the valve and the aorta were sized accordingly. A 21mm mechanical valve and 22mm Dacron grafts were selected and both were sutured. The left coronary button was sutured to the conduit followed by the right coronary button. Bentall procedure was performed safely with the composite button technique as described in this report.

Case Report

Mrs. Savitha a 39-year-old female patient came to the hospital with the symptoms of shortness of breath and chest pain. The 2D echo shows a bicuspid aortic valve with severe aortic stenosis and severe aortic regurgitation, Moderate mitral regurgitation (MR) with fair left ventricular (LV) function. The patient was small-sized with a body surface area (BSA) of 1.1m2. A Computed tomography (CT) aortogram was done on suspicion of a dilated aorta and a bicuspid aortic valve on echo finding. Abnormal dilatation of the proximal aorta was suggestive of a type II-A aortic aneurysm extending from the aortic root to the origin of the innominate artery that is proximal to the arch of the aorta. Biochemical tests showed normal levels of CBP(Hb-11.8 , WBC - 10.900 , Platelet Count -2.01/cumm), LFT(Total Bilirubin-0.6mg/dl, SGPT-21,SGOT-31), RFT(Urea-25, SR. Creatinine-0.7, TSH-2.15, PT with INR, and CTBT). Chest X-ray showed dilated ascending aortic shadow and normal CT ratio; ultrasound abdomen was normal; Carotid Doppler test showed mild diffuse atherosclerotic changes noted in all arteries which consist of a common carotid artery(CCA), internal carotid artery (ICA), external carotid artery (ECA).

Operative Findings

Moderate cardiomegaly and ascending aorta were huge in size. The aortic root, annulus and the Sino tubular junction were dilated, and the aortic valve was bicuspid and heavily calcified. There was calcification of the annulus with concentric Left ventricular hypertrophy (LVH).

Operative Procedure

Median sternotomy was performed, where the pericardium was opened, and the pericardial stay sutures were taken. After adequate heparinisation, cardiopulmonary bypass (CPB) was instituted through RA-Aortic cannulation (the aorta was cannulated just proximal to the origin of the innominate artery before the arch of the aorta). Heart arrested in diastole through selective ostial Del Nido cardioplegia. Then LV was vented through the right superior pulmonary vein (RSVP). Aorta was excised extending from the aortic root to the proximal arch. Aortic commissures and coronary Ostia were isolated and prepared. The bicuspid aortic valve was excised and after thorough decalcification, the valve and the aorta were sized and accordingly 21 mm mechanical valve and 22mm Dacron grafts were selected and both of them were sutured together. Multiple pre-pledged 2-0 polypropylene sutures were taken around the aortic annulus and the valved conduit was seated through the parachute technique.

The later conduit was sutured to the annulus with 5-0 prolene continuous sutures. The left coronary button was sutured to the conduit with 5-0 prolene continuous sutures followed by the right coronary button. After completing the proximal anastomosis and the coronary buttons, distal anastomosis of the bevelled conduit was performed onto the proximal end of the arch of the aorta using 5-0 prolene continuous sutures. After securing adequate hemostasis the patient was gradually weaned off by cardiopulmonary bypass (CPB) and heparin was reversed for the patient to decannulate. Mediastinal drains were placed, and the chest closed in layers with steel wires to the sternum and vicarly to other layers.

Contributors

Dr A R Krishna Prasad

Director and Chief Consultant Cardiothoracic Surgeon

Dr Vanu Aleti

Consultant Cardiac Anasthesia