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Ann Thorac Surg 2001;71:2050-2052
© 2001 The Society of Thoracic Surgeons

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How to do it

A new modified Bentall procedure: the flanged technique

^a Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Istanbul, Turkey

Accepted for publication December 20, 2000.

Address reprint requests to Dr Yakut, Kouyolu Kalp Eitim ve Aratirma Hastanesi 81020, Kadiköy, Istanbul, Turkey
e-mail: kosuyolu{at}superonline.com

	Abstract

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Replacement of the aortic root with a composite graft containing a prosthetic mechanical valve is the preferred surgical procedure for tailoring the aortic root. A new composite graft is designed with an extension below the prosthetic valve. The flange of the graft is anastomosed to the aortic annulus with a continuous suture. The remainder of the procedure is performed in the usual fashion, with button coronary anastomoses. This method is an alternative to previously described Bentall procedures for all aortic root pathologies, especially in cases with small aortic root precluding root enlargement and in those with defects at the annular and subannular areas that require repair.

	Introduction

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Modified Bentall methods have many beneficial effects like reduced tension on button coronary anastomoses, prevention of excessive bleeding and development of false aneurysms, avoidance of kinking of coronary arteries, decreased cross-clamp and operative time, and performance of complete aortic root replacement with the lowest mortality and morbidity rate [1–4].

A new modification (the flanged technique) adds two advantages in addition to the ones mentioned: enables aortic root enlargement and repair of iatrogenic subvalvular defects occurring during aortic root operations.

	Technique

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For cardiopulmonary bypass, femoral arterial cannulation is used in patients with aortic dissection who require hypothermic circulatory arrest or if the aneurysm extends to within 2 cm of the innominate artery. Venous return is achieved by bicaval cannulation. On the other hand, in patients with normal distal ascending aorta not requiring retrograde cerebral perfusion, we prefer the ascending aorta and single venous cannulation. Myocardial protection is maintained through retrograde continuous isothermic blood cardioplegia. The heart is vented through the right superior pulmonary vein. Aorta is then completely transected at the sinotubular junction and distally 2 cm from the cross-clamp. The coronary buttons are excised with a 1.5-cm diameter cuff of aortic wall and mobilized over a short length to facilitate reimplantation. A segment (5 or 6 mm in length) of the proximal end of vascular graft is everted outward to form the flange of the graft (Fig 1A). Then, a mechanical valve is inserted into the graft, which is fixed from four corners to the graft with 4-0 polypropylene sutures. A continuous 4-0 polypropylene suture is used to anastomose the bottom border of the stent of the prosthetic valve to the graft (Fig 1B). Then, the flange of the conduit is returned to its original position (Fig 1C), and implanted to the aortic annulus with a continuous 3-0 polypropylene suture. The length of the flange (1 to 3 cm long) is adjusted depending on the procedure (ie, aortic root enlargement or subannular area repair) (Fig 1D). First, the left coronary button is implanted with a continuous 5-0 polypropylene suture, and then the right coronary button is anastomosed. The distal anastomosis of the graft to the transected aorta is performed using a continuous 4-0 polypropylene suture. For arch replacement, total circulatory arrest with or without retrograde cerebral perfusion is performed after coronary ostia anastomoses.

View larger version (131K): [in this window] [in a new window]   Fig 1. Preparation of a flanged composite graft. (A) First, a segment of the proximal end of vascular graft is everted outward to form the flange of the graft. (B) A mechanic valve is inserted into the graft and sutured to the graft with a continuous 4-0 polypropylene suture to fix the bottom border of prosthetic valve to the graft. (C) The flange of the conduit is returned to its original position. (D) The flanged composite graft is ready for aortic root replacement. The length of the flange can be adjusted accordingly depending on the procedure to be performed.

	Comment

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The button technique is more time-consuming and difficult than a Bentall repair and has a lower initial survival rate for the first year after operation but a better survival rate thereafter [1]. The Cabrol technique can be preferred for patients undergoing reoperation or complicated repairs or when tension on the ostial anastomoses may occur. Technical problems, such as perioperative myocardial infarction, right ventricular dysfunction, and bleeding, still cause mortality.

Since 1996, we have performed all our aortic root replacements (80 patients) using a flanged composite graft with a hospital mortality of 8.75% (n = 7). No patient died of flange-related complications and none of the patients have undergone reoperation (for any cause). This alternative technique for aortic root replacement is not time-consuming and has better early and late results than the button technique [5].

In recent years, stentless bioprostheses, pulmonary autografts, and aortic allografts have been used for aortic root replacement in selected pathology to restore aortic annular physiology [6]. The major advantage of these methods is to replace aortic root with the most similar prosthesis. Their disadvantages are the mismatch between aortic annulus and the annular size of biological prosthesis and the limitation of usage only in selected patients. The function of the aortic valve is intimately related to the expansion of the aortic root. Thus, nondistensible stent designs may affect its performance. This new modification of Bentall technique achieves the continuance of the flexibility and elasticity of the aortic annulus without the limitations of usage.

The aortic annulus and the 3- to 5-mm proximal part of the ascending aorta, which remains over from the transected aortic wall, can be used as a strip over the proximal anastomosis to prevent surgical bleeding. Continuous suture technique prevents any bleeding problems caused from the proximal anastomosis. When the aortic annulus is intact, the flanged part of graft is usually prepared 5 mm in length. On the other hand, if an aortic root enlargement must be performed (in cases with small aortic annulus) or there are iatrogenic defects at the annular or subannular areas that require repair, the flange should be prepared more than 10 mm in length.

We prefer larger diameters for vascular grafts than prosthetic valves. After the anastomosis of the bottom border of prosthetic valve to the graft, a sinus is created around and above the prosthetic valve. The suture line of the aortic valve within the prosthesis comes at a little higher level than in a classic button technique, but it is never more than 4 to 5 mm. The new sinus allows the reimplantation of the coronary arteries without any problems. The two coronary buttons do not require greater mobilization. They are also not located more distally and not subject to tension.

In summary, although many different types of the button technique are used for aortic root replacements, only stentless bioprosthesis, allografts, or homografts can continue the geometric and physiologic shape of the aortic annulus. The new modification of the button technique described in this article allows this physiologic effect. This method can be an alternative for tailoring the aortic root in all aortic root pathologies, especially in patients with small and calcified aortic roots with calcification extending into mitral apparatus precluding a root enlargement (a Nick’s or Manougian technique) or in those with iatrogenic defects at the annular and subannular areas that require repair.

	References

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1. Kouchoukos N.T., Wareing T.H., Murphy S.F., Perrillo J.B. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308-320.[Medline]
2. Westaby S., Katsumata T., Vaccari G. Aortic root replacement with coronary button reimplantation: low risk and predictable outcome. Eur J Cardiothorac Surg 2000;17:259-265.[Abstract/Free Full Text]
3. Dossche K.M., Schepens M.A.A.M., Morshuis W.J., de la Riviere A.B., Knaepen P.J., Vermeulen F.E.E. A 23-year experience with composite valve graft replacement of the aortic root. Ann Thorac Surg 1999;67:1070-1077.[Abstract/Free Full Text]
4. Langley S.M., Rooney S.J., Dalrymple Hay M.J., et al. Replacement of the proximal aorta and aortic valve using a composite bileaflet prosthesis and gelatin-impregnated polyester graft (Carbo-Seal): early results in 143 patients. J Thorac Cardiovascular Surg 1999;118:1014-1020.[Abstract/Free Full Text]
5. Yakut C, Iik Ö, Kirali K, et al. Comparison between Bentall, and flanged techniques. VII Aortic Surgery Symposium, April 27–28, 2000, New York, New York.
6. David T.E., Omran A., Webb G., Rakowski H., Armstrong S., Sun Z. Geometric mismatch of the aortic and pulmonary roots causes aortic insufficiency after the Ross procedure. J Thorac Cardiovasc Surg 1996;112:1231-1239.[Abstract/Free Full Text]

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