Modified Bentall procedure: A 15-year single-center clinical experience

OBJECTIVE

Bentall procedure is a standard technique for complete aortic root replacement but a huge challenge is postoperative bleeding. Many modifications have been proposed and the "button technique" is commonly used. With a 15-year experience, this study was to evaluate outcomes of this modified Bentall procedure.

METHODS

A retrospective study was performed with all patients who underwent the Bentall procedure with a button technique between 2005 and 2020. Commercially available composite grafts were used in 38 patients and self-assembled composite graft was used in 74 patients. Safety outcome was postoperative complications and long-term outcomes included overall and reoperation-free survivals.

RESULTS

Among 112 patients, the mean age was 46.3 years and 69.6% were men. Indications for the Bentall procedure were ascending aortic aneurysm and valve regurgitation (59.8%), aortic dissection (19.6%), Marfan syndrome (17%), and endocarditis (3.6%). Three patients (2.7%) died in hospital. During a median follow-up period of 42 months, 11 patients died and 7 patients required reoperation. Overall survival and reoperation-free survival were 86.1% and 83.4% at 5 years and 86.1% and 72.6% at 10 years, respectively.

CONCLUSIONS

The Bentall procedure with a button technique is safe and effective for aortic root replacement. Further investigations are required to improve the feasibility and effectiveness of the procedure.

Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay

OBJECTIVE

Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery.

METHODS

During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not.

RESULTS

Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028).

CONCLUSIONS

In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.

Impact of sinuses of Valsalva on prosthesis durability in patients undergoing ascending aorta and aortic valve replacement with Carpentier-Edwards bioprosthesis: a propensity score-based study

OBJECTIVES

The effect of sinuses of Valsalva on aortic bioprosthesis durability has not been investigated so far. The aim of this study was to compare durability of the Carpentier-Edwards aortic bioprosthesis in patients undergoing aortic valve and ascending aorta replacement as a composite bioconduit (Group A, case group) versus patients undergoing separate replacement of the aortic valve and ascending aorta, with preservation of the aortic root (Group B, control group), between January 2000 and January 2014.

METHODS

Records of Group A (n = 133) and Group B (n = 162) patients were retrospectively reviewed. End-points were evaluated among groups in three ways: before and after propensity score 1:1 matching (Group A, n = 94; Group B, n = 94 patients) and after patient stratification through quintiles of propensity scores.

RESULTS

There was no difference among groups regarding mean and maximal trans-prosthetic pressure gradients at discharge (P = 0.07 and 0.45, respectively). Maximal trans-prosthetic gradients were lower in Group A patients at last control (P = 0.03). Structural valve deterioration (SVD) was due to prosthesis regurgitation (Group A, n = 5; Group B, n = 1), stenosis (Group A, n = 2; Group B, n = 5) or combined (Group A, n = 4; Group B, n = 2). After a mean follow-up of 68 ± 42 months, there was no difference among groups, at 5 and 12 years, regarding mortality, freedom from SVD, from redo aortic valve replacement for SVD and cardiac redo of any type, before and after matching and after stratification according to quintiles of propensity scores.

CONCLUSIONS

Within the 12-year follow-up, the absence of the sinuses of Valsalva seems to have no influence on durability of Carpentier Edwards aortic bioprosthesis. Longer follow-up may be warranted.