Complex Bentall Operation: Clinical Pearls to Standardize the Procedure

Background: A straightforward Bentall operation can be performed safely with low mortality, but some challenging cases require a more complex operation. We discuss here the steps of the Bentall procedure. Methods: We reviewed specific scenarios, such as acute aortic dissection, native valve or prosthetic valve endocarditis, redo Bentall after aortic root replacement, calcified aortic root, and patients with prior coronary artery bypass grafting, mechanical aortic valve replacement, stentless aortic valve replacement, and prior extensive aortic arch repair with proximalization of neck vessels. Results: A variety of techniques were reported regarding reconstruction of aortic annulus (eg, Dacron [DuPont] graft is everted to create 5 to 6 crimps when sewing a bioprosthesis, and the height of the skirt can be adjusted depending on tissue defect) and reimplantation of coronary buttons. (Interposition of Dacron graft for coronary button reimplantation [original Cabrol technique], short interposition of Dacron graft is known as the Piehler technique, and technique in redo Bentall after prior aortic root replacement.) In patients with a history of coronary artery bypass grafting, direct reimplantation of a previous vein graft patch to the Dacron graft or interposition of a short Dacron graft were introduced. In addition, repair of coronary button in type A dissection or calcified aortic root were also described. Conclusions: Various techniques are available in modified Bentall operation. Surgeons should be familiar with the setup, anatomy of aortic root and surrounding structures, ways to treat tissue defect and prepare coronary buttons, and the various bailout procedures.