Bentall Procedure: Top 5 Facts to Know

The Bentall procedure is named after its creator, Dr. Hugh Bentall. It is a surgical technique the doctor and his colleague, Dr. A. De Bono, pioneered in the latter part of the 1960s for the "repair of an ascending aortic or aortic root aneurysm in combination with aortic valve disease." This procedure has saved countless lives since its inception. Dr. Bentall's technique has also been modified and expanded upon to provide quality intervention to a more extensive range of indications that require an aortic root replacement. It is certainly not the one-and-only go-to for all, but it is considered the standard against which other like-procedures are compared.

Fact #1: Indications for the Bentall Procedure

Aortic valve regurgitation, aortic aneurysm, Marfan's syndrome, and aortic dissection are some of the diagnoses that might require replacement of the aortic root, aorta, and the aortic valve.
To make this word soup more understandable, let's first take a look at the anatomy of this area of the heart. The aorta is the largest artery in the human body. Oxygenated blood is pumped from the left ventricle through the aortic valve, where it then moves through the ascending and descending aspects of the aorta to the rest of the body. The aorta has four parts: the ascending aorta, the aortic arch, the thoracic (descending) aorta, and the abdominal aorta. The ascending aorta is addressed here. It measures approximately 5 centimeters in length with a diameter of about 3 centimeters. Its diameter becomes smaller as it moves away from the heart. The aortic root is the section of the aorta that is attached to the heart. The aortic valve is located here. The openings where the coronary arteries attach are part of the aortic root, as well.

An aneurysm is a bulge in a vessel wall, usually caused by a weakening of the tissue. An aortic aneurysm, depending on size and exact location, can cause back pressure, which acts on the aortic valve. The aortic valve can become problematic, not working properly, causing blood to leak back into the heart. The result is higher pressure in the heart. This result is called aortic valve regurgitation.

An aneurysm can also lead to aortic dissection. Aortic dissection occurs when a tear occurs in a layer of the bulging area of the aorta. Blood flows through this tear, which causes the layers to separate. The arterial wall bursts as the blood flow is interrupted.

Marfan Syndrome is a genetic disease of the connective tissue. In its more severe form, the aorta walls are weakened and can develop bulges (aneurysms). There is no cure for this condition. However, it can be managed with medications, surgery, and other treatment modalities dependent on exhibited signs and symptoms.

Fact #2: Diagnosis and Treatment

There are standard laboratory and radiology exams that are ordered for most cardiac-related pathology. They may include:

• Chest x-ray
• EKG
• Echocardiogram
• CT scan
• MRI
• Comprehensive blood tests

Your doctor will discuss his findings with you and give you his recommendation(s) for treatment. Your physician takes into consideration your overall health, the lab, X-ray, and other diagnostic test findings, and the condition of your aortic valve, root, and ascending aorta when deciding on treatment. If the Bentall procedure is what your surgeon suggests, he or she will need to determine whether or not to replace your aortic valve. If it is decided that the aortic valve replacement should be included, there will be the question of whether a mechanical or biological valve will be used.

Mechanical valves often outlast the patient. They do, however, require taking anti-coagulant medications for the rest of your life. This means that you could have a higher incidence of bleeding and would, therefore, need regular monitoring.

Biological valves wear out sooner than their mechanical counterparts. 15-20 years is an average life expectancy for these. You might, eventually, need another surgery to replace the valve somewhere within that time frame.

Fact #3: What Happens During Bentall Procedure?

As with any surgery performed when the patient is given a general anesthetic (put to sleep), you will be required to cease any intake of fluids and solid food the night before. Your surgeon will have specific instructions for you to follow regarding the taking (or not) of your regular medications, any pre-surgery cleansing, etc.

The actual surgery is usually completed in 5-6 hours. Access to your heart is most often gained through a large incision through your sternum (breast bone). During the surgery, you will be kept asleep by the anesthesiologist (a doctor) and placed on a heart-lung bypass machine allowing your surgeon to temporarily stop your heart. The bypass machine stands in for your heart and lungs circulating oxygenated blood to your body.

The surgeon will clamp the aorta above the diseased portion and then resect (remove) the weakened segment of the aorta and aortic valve. Your coronary arteries will also be removed temporarily. A man-made graft with the valve already in place is stitched to the healthy end of your aorta and your heart. Your coronary arteries will be sewn to the graft as well. The clamp is removed, and the heart-lung bypass machine stopped as your heart is restarted. The doctor observes the blood flow before stitching the chest incision closed.

After your surgery, you will spend 1-2 days in the intensive care unit. You can expect to be sitting up at your bedside within 24 hours despite the chest tubes and iv lines. You will be sore. It is not uncommon to initially move with a sense of trepidation. When released from ICU, it is standard to spend 3-5 days in the cardiac ward. Your heart rhythm and other vital functions will be closely monitored. The nurses will teach you wound care and the safest methods to move your body while protecting your breastbone. It can take up to 8 weeks for your sternum to heal.

When you are discharged home, it will be important to progress slowly. Plan to have help for the first few weeks. Healing takes time.

Fact #4: The Risks/Complications of Bentall Procedure?

The risks associated with the Bentall procedure include infection, bleeding, arrhythmias (abnormal heartbeats), stroke, and some people experience temporary short term memory loss and difficulty with concentration, clot formation, heart attack, kidney failure, and death. Your surgeon should discuss the likelihood of each of these before you give your consent to operate.

It cannot be stressed enough that cigarette smoking is one of the highest risk factors associated with any cardiac surgery. It is common for smokers to experience extended assisted-ventilation times. Coupled with other pre-existing conditions such as diabetes, the risk for complications during the surgery or postoperatively is significantly compounded.

Fact #5: Long-Term Outcome After A Bentall Procedure

Depending on which research study one reads, long term survivability ranges from 70-92 percent at five years and 60-75 percent at ten years. This is not to say that those survivors did not have any other medical issues or complications associated with the surgery many years down the road. What it does point to, the way I understand it, is that, with regular follow-ups and attention to self-care, patients can look ahead to many more years!

You Might Also Like

To help educate and empower you about aortic aneurysms, you may like:  

• Surgeon Roundtable: Bentall Procedure versus Valve-Sparing Aortic Root Replacement
• Surgeon Q&A: Annual Growth Rates of Aortic Aneurysm
• Patient Story: How Did 4D-MRI Help John Time Aortic Aneurysm & Bicuspid Valve Surgery?
• Cardiac Innovation: Valve-Sparing Aortic Root Replacement for Bicuspid Valve Patients

References:

-https://www.merriam-webster.com/dictionary/aneurysm
-https://teachmeanatomy.info/abdomen/vasculature/arteries/aorta
-https://www.sciencedirect.com/science/article/pii/S0140673613605711
-https://www.svhhearthealth.com.au/procedures/procedures-treatments/bentall-procedure
-https://ghr.nlm.nih.gov/condition/marfan-syndrome
-https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?HwId=
-https://www.optechtcs.com/article/S1522-2942(18)30118-1/abstract
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-jtd.amegroups.com › article › download › pdf
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