Bentall procedure

The Bentall procedure is a type of cardiac surgery involving composite graft replacement of the aortic valve, aortic root, and ascending aorta, with re-implantation of the coronary arteries into the graft. This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with Marfan syndrome. The Bentall procedure was first described in 1968 by Hugh Bentall and Antony De Bono. It is considered a standard for individuals who require aortic root replacement, and the vast majority of individuals who undergo the surgery receive mechanical valves.

Since its inception, the Bentall procedure has been considered a gold standard of aortic valve replacement.

Importantly, the use of mechanical vs biologic valves are not predictive of quality of life overall, morbidity and mortality. General guidelines for the repair of valvular heart disease indicate the medical team takes into consideration the following patient factors for the determination of best conduit to use: age, life expectancy, lifestyle choices (diet, exercise, hobbies, risk of potential falls/ physical trauma), medical history (history of stroke or blood clots), likelihood of surgical or transcatheter repeat procedure, and of course patient preference.

The Bentall procedure is considered for patients who may have Marfan syndrome, aortic dissection, aortic root aneurysm, aortic regurgitation of the valve, calcification of the aortic valve, and congenital anomalies.

Early Morbidity and Mortality Within 30 days of hospitalization, morbidity and mortality after Bentall procedure are associated with complications stemming from cardiac arrhythmia, pneumonia, acute respiratory distress syndrome (ARDS), sepsis, graft infection, wound infection, neurologic/ cerebrovascular accident and stroke, hemorrhage/ bleeding, myocardial infarction, pericardial effusion, organ damage/ deterioration. Overall, these complications are seen in < 6% of patients undergoing this procedure, with risk of complications being greatly associated with other preexisting risk factors and comorbidities.

Like early morbidity and mortality, infection of a graft after Bentall Procedure is rare affecting < 5% of cases, but can be of very serious consequence to the patient. Many of these patients who develop infections have multiple comorbidities and risk factors existing before the surgery including diabetes, suppression of the immune system, preexisting cardiovascular issues outside of the direct indication for a Bentall procedure and cancer.

Graft infection from a Bentall procedure presents similarly to many infections after a major cardiac surgery, with indications in various degrees of severity. Symptoms can include fever, chills, loss of appetite, weight loss, malaise with clinical indications including septic emboli, abscess, left ventricular fistulae, transient ischemic attack. These can occur weeks to years after the Bentall procedure itself.

If a patient is suspected to have a graft infection, they should immediately seek medical attention. Evaluation of an infection may include blood work including CBC, CMP, blood cultures. Further assessment and imaging may involve transesophageal echocardiography, CT scan, CT Angiography, PET scan. Depending on the modality, evidence of infection includes: increased glucose uptake, pseudoaneurysm, fistula, fluid/ attenuation around the graft (indicating increased inflammation), or other increased signs of inflammation around the graft; these findings are then taken into account and assessed in the context of the clinical/ symptomatic picture of the patient.