Revisiting bentall procedure
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This document discusses the Bentall procedure for treating type A aortic dissection and revisits its use. It provides an overview of the history and anatomy relevant to the procedure. It then summarizes some studies comparing outcomes of the Bentall procedure versus the Ross procedure or valve-sparing surgery for acute type A dissection. The document concludes that the Bentall procedure remains a safe and less painful option for aortic root dissection with reasonable outcomes when the coronary buttons are properly placed.
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Revisiting bentall procedure
- 1. REVISITING BENTALL PROCEDURE for Type A Aortic Dissection Dicky A.Wartono ,MD Harapan Kita National Cardiovascular Centre Harapan Kita Jakarta 2016
- 9. • Complete replacement of Aortic Root & Valve, with re-implantation of the coronary arteries into the graft • Hugh Bentall & Antony De Bono • London 1968
- 10. The anatomy of the sinus of Valsalva Kenneth Reid Thorax 1970 25: 79-85 doi: 10.1136/thx.25.1.79
- 12. AORTIC ROOT PATHOLOGY Congenital Infection/inflamation Trauma Others Dissection Aneurysm Concomintant Valve Dis -AS/AR -Bicuspid Aortic Valve (BAV) ROSS (Mod)BENTALL VALVE SPARRING
- 15. What is the better choice for acute type A dissection Bentall vs VSSR Author N B/VSSR Mean f/u survival Event free survival Bernhard A., Reichenspurner et al. 2011 30/58 3.2 y 14Y-87% B 14Y-89%VSSR 14Y-48% B 14Y-44% VSSR Freedom from Reoperation Bekkers JA, Boggers Ad et al 2012 75/157 7.2 Y Overall 10y- 53.4% without significant difference 10y-100% B 10Y-85% VSSR without significant diff. Subramanian S, Mohr FW et al 2012 130/78 7.2Y Overall 8y-55% without significant diff Overall 8y-95% without significant diff.
- 16. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases 30mm = Aneurysm >55mm = Surgery >50mm = Bicuspid >45mm = Marfan
- 18. European Society of Cardiology task force on acute type A Dissection
- 19. Outcomes 15 Years After Valve Replacement With a Mechanical Versus a Bioprosthetic Valve: Final RCT on hogh rist pts Ann Thorac Surg 2014;76:698–703
- 20. Kaplan-Meier curves of event-free survival Kaplan-Meier curve of survival Outcomes 15 Years After Valve Replacement With a Mechanical Versus a Bioprosthetic Valve: Final RCT on hogh rist pts Ann Thorac Surg 2014;76:698–703
- 23. Operation step
- 24. General considerations • Establishing CPB in traditional way. – W/o cross clamping – Rt radial a. line/ femoral a. line opposite to cannulation site. – Routine TEE • If FEM-FEM bypass is chosen. – CFA with the most normal pulse – CFV on the right should be used ( easily positioned to RA )
- 26. Axillary Cannulation Advantages Disadvantages • Antegrade perfusion. • No manipulation of the ascending aorta. • Recomended over femoral cannulation as prophylaxis against malperfusion, lower extrmity ischemia,retrograde dissection and retrograde embolization of debris • Time consuming. • Impossible to CNS perfusion if dissected. • Brachial plexus injury. • Vascular complication. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999 Axillary cannulation in acute ascending aortic dissections Ann Thorac Surg 2000
- 27. • On Bypass… temp 28.. VF • (Clamp)… Aortotomy • Composite implantation • L-button • Temp 22’C.. HCA • Open distal anastomosis • Re warm.. Aortic Clamp… R button
- 28. Aortotomy & Periaortic dissection (Excise aortic valve leaflets) Coronary button Preparation
- 29. Prostetic suture
- 30. Prostetic suture
- 31. Implantation of the Left coronary into the graft
- 34. Better survival with extended approach
- 35. Results • No difference in late all cause mortality The Addition of the Hemi‐Arch Replacement to Aortic Root Surgery does NOT increase Operative Mortality Badiwala M, Rinewalt D, Kruse J, Li Z, Andrei AC, McCarthy PM, Malaisrie SC. 2014 Addition of a hemi-arch replacement using DHCA to the modified Bentall Procedure does not significantly increase stroke and bleeding complications, nor mortality
- 36. Ann Thorac Surg 2003;76:499–502
- 38. Ann Thorac Cardiovasc Surg Advance Published Date: February 29, 2012
- 39. ANNALS OF SURGERY Vol. 234, No. 3, 336–343 © 2001
- 40. Ann Thorac Surg 2010;89:992–
- 41. Implantation of the Right coronary into the graft
- 43. Ann Thorac Surg 2002;74:1071–4
- 44. Meta Analysis Harapan Kita** Total Adjust* Total Adjusted* Bleeding Redo 18 1.4 22 2.1 Cardiac 3rd block 2.1 1.4 3 1 Inotropic Supp 56 21 76 18 VF 11 0.7 5 0 Respiratory 22 2.8 23 2 Chronic Dialysis 9 1.7 11.2 0 Infection 11 1.7 33 4.2 Mortality 22 1 18.8 1 Mean LOS 18 13.3 29 15 Ann Thorac Surg 2014;76:698–703 *Adjusted for unstab preop, multiple comorbidity, multiple procedures, redo bentall, conversion ** Data 2013-2016
- 45. • Conclusions • Bentall for Root Dissection, is a safest & less painfull option, with reasonable outcome • Timing of Surgery, & placement of coronary button is one of the most contributing factor • There are few option for managing fragile tissue
Editor's Notes
- Kaplan-Meier curve of survival of all patients after the Ben- tall operation (solid line). Overall survival is 0.95 (95% confidence intervals, 0.9 to 0.99) at 5 years and 0.93 (95% confidence intervals, 0.86 to 0.99) at 8 years. Shown for comparison is an age-matched and sex-matched curve for the US population (dotted line) Kaplan-Meier curves of event-free survival among the 142 patients who underwent a Bentall operation. Events include endocar- ditis, need for ascending aorta reoperation, stroke, or significant thromboembolic or bleeding complications (requiring hospitaliza- tion). Event-free survival is 0.85 (95% confidence intervals, 0.78 to 0.92) at 5 years and 0.78 (95% confidence intervals, 0.68 to 0.88) at 8 years.
- Excessive bleeding after aortic surgery is generally related to a combination of several alterations in the hemostatic system pertaining to the dilution and activa- tion of the coagulation system, which is mainly attributed to the use of extracorporeal circulation.
- The repair of spontaneous dissecting aortic aneurysms or iatrogenic aortic dissections can be very complex because of the extreme friability of the aortic tissue, the extent of damage to structures, and in many cases, secondary organ involvement [1, 2]. Many techniques have been used to reinforce the friable aortic tissue. Teflon felt has been amply used, but many times the resultant aortic cuff is tough and of small size. Bleeding from this graft– “sandwiched” aorta can be troublesome. Resorcinol glue, although extremely useful to reinforce the aortic tissues [7, 8], is not available in the United States. Topical 25% glutaraldehyde, as described by Vasseur and Hamond [9] for dissecting aneurysms and later by us for friable aortas [10], is very effective in toughening aortic tissue. How- ever, the procedure of applying the glutaraldehyde is tedious, and it can damage the surrounding tissue. The adventitial inversion technique described by Flo- ten and colleagues [3] is an effective method of modifying the friable aorta to create a tough but soft aortic cuff. The toughness ensures that the sutures hold without tearing. The softness allows the use of small needles and sutures to facilitate a hemostatic anastomosis. Their remarkably low (7.1%) mortality [3] alerted us to the versatility of this technique. Dissecting aneurysms can create practically unsolvable surgical situations. Our experience expands the use of the adventitial inversion technique to other complex surgical situations. Thus, most patients can be handled with the techniques outlined here. None of the 11 aortic cuff–graft anastomoses bled intraoperatively or postop- eratively. We recommend this simple technique to repair dis- secting aneurysms, because it has changed our percep- tion and approach to this highly complex problem. Our experience is small; thus, it is difficult to draw meaningful conclusions about the universal applicability of the tech- nique and long-term results. However, in 1995, Floten and colleagues [3] had treated 29 patients with excellent results in the short- and long-term follow-up.
- However, there are some experimental reports suggesting that, due to the extrinsic coagulation pathway via exposed adventitial collagen and tissue factor, inverted adventitia may elicit thrombus formation with subsequent emboliza- tion,4) although the thrombogenicity of inverted adventitia has not been tested clinically to our knowledge. Wishing to address this technique’s advantages and its potential complications, we integrated this method with our method of telescopic graft insertion.5) This resulted in complete coverage of the inverted adventitia, eliminating the potential risk of thrombus formation. Furthermore, reinforcement of the intima by two adventitial layers, an external felt strip, and tube graft (Fig. 1C) lead to com- plete hemostasis, eliminating the need for hemostatic stitches and resulting in stable anastomosis.
- Resection of the aortic arch and ascending aorta was undertaken and a Dacron tube graft was used as a replace- ment conduit. Felt or BioGlue was placed between the intima and adventitia to obliterate the false lumen and recreate a neo-media (Fig. 1). Hemiarch repair was used in 96 patients, and an extensive or total aortic arch replacement (elephant trunk procedure) was used in 8 patients. The primary tear site was resected in all patients. On completion of the aortic arch reconstruction, blood was allowed to occupy the native aorta and graft, allowing air and debris to be evacuated from the cerebrovascular system. The entire arterial circulation was deaired at this time via the RCP circuit. The arch graft was cannulated and then proximally cross-clamped, with RCP termination and resumption of arterial perfusion and rewarming directly through the aortic arch graft for antegrade perfusion. The aortic root was replaced or repaired depending on the pathology present. When repair was deemed possible, the aortic valve leaflets were resuspended using three pledgeted supracommissural sutures. The sinus of Valsalva segments were then reinforced with Teflon felt as a neo-media (Fig. Figure 1. Application of felt “neo-media” placed between adventitia and intima. 2), and more recently BioGlue was used as an adjunct. In 81 patients, the aortic root was repaired, and in 23 patients the aortic root was replaced with either a biologic or a mechan- ical valved conduit (see Table 2). Indications for the re- placement of the aortic root included bicuspid aortic valve (n 9), Marfan syndrome (n 10), Ehlers-Danlos syn- drome (n 1), primary abnormalities of the aortic valve leaflets, obvious sinus of Valsalva aneurysm, and extension of both the tear and dissection to the aortic annulus (see Table 2). TEE was used in all patients to assess the ade- quacy of the aortic root repair All patients received 1 g methylprednisolone (Solu-Medrol) intravenous bolus, 1 g MgS04 intravenous, 2.5 mg/kg lidocaine intrave- nous, and 12.5 g mannitol intravenous. These neuroprotec- tive agents were given immediately before initiation of CPB In conclusion, our data show improved survival and low postoperative stroke rates with the use of an integrated perioperative approach to acute type A dissection. Together, these measures create a new paradigm that consists of: 1. Rapid admission to the operating room for diagnosis and therapy 2. Intraoperative TEE 3. Neurocerebral monitoring 4. Routine open aortic arch reconstruction with RCP 5. Routine antegrade arch graft perfusion after comple- tion of arch repair 6. Aortic root repair and aortic valve resuspension in most patients when preexisting leaflet or root pathology is absent 7. Creation of a neo-media using either felt or BioGlue to New Paradigms for Acute Type A Dissection 341 strengthen the aortic and sinus walls and obliterate the false lumen.
- Persistent oozing and bleeding after aortic anastomosis can occur during aortic surgery. This may become uncontrollable because of severe coagulopathy, resulting from induced hypothermia, long cardiopulmonary bypass time, or fragile aortic walls by acute aortic dissection. There are a lot of methods used to prevent this bleeding, such as anastomosis techniques to reinforce a suture line, Bioglue (CryoLife Inc, Kennesaw, GA) for anastomosis, or wrapping methods, such as the Cabrol shunt, which have been reported [1–3]. However, these techniques are not always perfect and are too complex to perform for every anasto- mosis during a tough operation. In this report, we describe a novel wrapping technique with insertion of fat tissue between the anastomotic site and the Teflon felt (DuPont, Wilmington, DE), which is a simple, effective, and reliable technique, and should be useful to obtain perfect hemosta- sis on the suture line. Enough fat tissue is harvested, sometimes around the peripleura under the divided sternum. The thickness and width of harvested fat should be adjusted to bleeding conditions. The thickness of 1 mm is enough to be an even suture line like graft-to-graft anastomosis. However, 3-mm to 4-mm thickness is necessary to completely seal a bumpy surface after placing some stitches and pledgets. The width of 1-cm to 2-cm is enough to cover bleeding points. hen, harvested fat tissue is placed on a Teflon felt strip (DuPont) or a used prosthetic graft, which is 1.5-cm to 2.0-cm wide, and fixed to these using some interrupted stitches by a 5-0 Prolene suture (Ethicon, Somerville, NJ). Finally the anastomotic portion including bleeding points is wrapped by this composite felt. We can control the applied pressure by using our fingers, which will immediately reduce the bleeding. Then, both ends of the felt strip are tightened using interrupted sutures after confirming a perfect hemostasis (Fig 1).
- Report persistant fistula.. N RV failure.. Repair after 4 month 6mm goretext
- In aortic operations, we routinely enter the pericardial space by incising the pericardium along the border of the right pleural space and hang it to the left sternal half with stay stitches in order to prepare a patch of pericardium, measuring roughly 22 inches when needed for a peri- graft to right atrial fistula (Fig 1). It is important to close the transverse sinus to prevent posterior leakage in first-time operations. For this pur- pose posterior wall of the left atrium can be sewn to the anterior aspect of the right pulmonary artery by taking shallow bites. For redo operations, it is not necessary to close the transverse sinus, because of the adhesions. We use 5/0 polypropylene for construction. Inferiorly, suturing starts at the epicardium of the right ventricular wall, continues towards the main pulmonary artery by taking bites from the adventitia. The Teflon felt at the distal suture line constitutes the superior border of the patch (Fig 2). Medially sutures can be placed to the posterior pericardium and then to the lateral aspect of the superior vena cava towards the base of the right atrial appandage (Fig 3). Care should be taken to avoid injury to the sinus node. Before completing the suture line, a large stab wound is created on the medial aspect of the right atrium and this hole is enlarged with the tip of a forceps. The perigraft space is then closed expeditiously (Fig 4). One patient with the right coronary ostium dissection required coronary artery bypass grafting. The proximal anastomosis of the vein graft was constructed to the right brachiocephalic artery after creation of the shunt. The decision to construct a shunt was made when significant bleeding persists about 20 to 30 minutes after the administration of protamine, despite the transfusion of fresh frozen plasma (FFP), fresh whole blood, throm- botic agents, and mechanical packing Hoover and associates [2] preferred graft interposition instead of a direct shunt, because the grafts may be more likely to thrombose and if not, they can be embolized with coils. Cabrol and associates [5] reported persistent left to right shunt in 3 of 260 shunt procedures.