Bentall Operation: Early Surgical Results, Seven-Year Outcomes, and Risk Factors Analysis

Abstract

Aim: To analyze early and mid-term outcomes of the Bentall operation. Methods: Two hundred and seventeen patients (mean age 65.6 ± 15.9 years, males/females 172/45) underwent Bentall operation in a 7-year period (January 2015–December 2021), on average, 30 Bentall operations occurred per year, using biological (n = 104) or mechanical (n = 113) valved conduits for the treatment of ascending aorta–aortic root aneurysms. Associate procedures were performed in 58 patients (26.7%); coronary artery bypass grafting (CABG) in 35 (16%). Mean follow-up was 55.2 ± 24 (median 60.2) months. Cox model analysis was used to assess risk factors, Kaplan–Meier and log-rank tests were used to assess different survival rates. Results: Operative mortality was 1.38%. At 7 years, survival, freedom from cardiac death, and event-free survival were 93% ± 2%, 99% ± 1%, and 81% ± 5%. NYHA class (p < 0.0001), trans-aortic valve mean (p < 0.0001) and maximum (p < 0.000) gradients, left ventricular hypertrophy (p < 0.05), and pulmonary arterial pressure (p = 0.002) significantly improved vs. preoperative values. Concomitant CABG during Bentall operation independently affected late outcomes (HR 1.9–2.3; p-values < 0.05). Late survival was affected by concomitant CABG (84% ± 8% vs. 95% ± 2%, p = 0.04), preoperative myocardial infarction (91% ± 9% vs. 97% ± 2%, p = 0.02), and biological vs. mechanical prostheses valved conduits (91% ± 9% vs. 95% ± 3%, p = 0.02). Event-free survival also was affected by concomitant CABG (62% ± 14% vs. 85% ± 5%, p = 0.005) and biological prostheses (78% ± 8% vs. 84% ± 6%, p = 0.06). Freedom from endocarditis–redo operation was 83% ± 9% for biological prostheses vs. 89% ± 6% for mechanical prostheses (p = 0.49). Conclusions: Low rates of operative mortality and late complications make Bentall operation the gold standard for the treatment of ascending aorta–aortic root aneurysms. Coronary ischemic disease affects late outcomes. Biological prostheses should be preferred for the elderly.

Impact of Aortic Root Abscess on Surgical Outcomes of Infective Endocarditis

“…In the examined population, there was no observed increase in the incidence of postoperative complications in the Bentall group, suggesting that a careful technique in the reimplantation of the coronary arteries and aortic root can effectively mitigate the risk of postoperative myocardial ischemia. Divergent from our results, another study found that the Bentall procedure was associated with a longer operation time, longer bypass time and aortic clamping time, which has been shown to increase in-hospital mortality [21]. Although the AVR + RR group had a lower mean EuroSCORE II compared to the other groups, the mortality rate within the initial 30 days was the highest in this group in terms of percentages.…”

How Refined Surgical Technical Solutions Can Make Bentall Operation a Low-Risk Procedure: 20-Year Personal Experience at the “Root” of the Aortic Diseases—It Is Time to Change Surgical Guidelines

“…The earliest surgical indication to treat aneurysms, with a diameter of 50 mm, underlies two important aspects that we want to underline: first, that the risk of rupture/dissection/sudden death for aortic dilations between 45 and 50 mm is reported to be between 4 and 7% per year, and therefore appears higher (2-3 times) compared to the mortality observed in our study; second, that the operative risk for the treatment of acute aortic complications is 15-20 times higher when the surgical intervention is performed in emergency. This decision was also supported by important studies [11,12,16] performed in our center that questioned the role of the aortic diameter in order to prevent catastrophic complications like rupture and acute dissection. Our surgical indication was also based on etiological parameters and on morphological features, i.e., coronary ostia dislocation and prolapse, quality of the aortic wall, asymmetric dilation of Valsalva sinus/sinuses, aortic-annulus disjunction, and presence of the heart muscle through the aortic annulus without endothelium (Figure 7) at the level of right-or non-coronary sinus.…”

“…Experienced centers performed the Bentall operation with very good postoperative results. Additional coronary artery disease could influence late outcomes [12,20]. Specific expedients in surgical technique can greatly improve the results.…”

“…According with our experience [11][12][13][14][15][16], surgical indication was based not only on a smaller diameter (≥5.0 cm for sporadic thoracic aortic aneurysms (TAA) and ≥4.5 for syndromic TAA with or without aortic valve dysfunction) than that advocated by the EACTS/ESC guidelines [17], but also on etiological parameters and on morphological features, like coronary ostia dislocation and prolapse, quality of the aortic wall, aortic-annulus disjunction, i.e., asymmetric dilation of Valsalva sinus/sinuses [15] (Figure 1). Obviously, preoperatively, all patients gave their surgical consent after being informed about the differences between the international guidelines and our different personal surgical indications.…”

The key role of miRNA in syndromic and sporadic forms of ascending aortic aneurysms as biomarkers and targets of novel therapeutic strategies

“…Currently, therapeutic treatments for all ATAAs, such as antihypertensive drugs, are not specific and poorly effective, so patients undergo surgery to remove the portions of the aorta that tend gradually but not rapidly to dilate. Moreover, most patients with ATAA eventually require surgical repair of the aneurysm, with mortality risk ranging from 1% to 5% for elective repair ( Piano et al, 2021a ; Asano et al, 2022 ; Nardi et al, 2022 ) and up to 12% for emergency surgery ( Piano et al, 2021b ; Asano et al, 2022 ; Nardi et al, 2022 ). Another typical feature of ATAA is the high phenotypic variability, which is well documented in all the forms of ATAA, but particularly in genetically triggered ATAA, in which the same pathogenic genetic variant can lead to different clinical manifestations ( Salmasi et al, 2023 ).…”