Composite Graft Aortic Root Replacement: Bentall Procedure

Abstract

Composite graft replacement (Plate 52.1 and Video 52.1) of the aortic root is a very serious operation. In a nosology of adult cardiac surgical procedures, composite graft replacement was rated the highest acuity procedure.

Questions and Answers

• BAZ: How about bleeding after the Bentall operation is completed? How can that be handled?

• JAE: The Bentall operation has consistently been rated the highest acuity operation in adult cardiac surgery. The potential for bleeding is one reason. (The potential for total ischemia in either the right or left coronary distributions is another.) Once the Bentall graft is completed and the aorta unclamped, on-going bleeding is extremely serious.

• It is almost impossible to control bleeding from the proximal anastomosis. Perhaps one can place a stitch or two if the bleeding site is in the anterior or lateral portions of the proximal anastomosis (although the right coronary button impedes and jeopardizes such efforts). However, the posterior portion of the proximal anastomosis is essentially impossible to control.

• If the bleeding is from the right coronary button, it is usually feasible to gain exposure and to place additional sutures. This may be done with or without resuming CPB. We have noted that once the aorta is pressurized, the coronary button tissue (now on stretch by the arterial pressure) becomes extremely friable. For this reason, we support any extra sutures (mattress type) with a tiny pericardial pledget on the button side—in order to avoid tearing. Once this tissue starts to tear, the problem becomes even more serious.

• The left coronary button is very difficult even to expose and even more difficult to supplement with additional sutures. In case of a left coronary button anastomotic problem, it is probably best to resume bypass, open the graft, and repair the coronary anastomosis from the inside—by additional tightening and supplemental sutures.

• Any stitches added after weaning CPB, for the right or the left button, run the risk of narrowing the anastomosis and creating life-threatening ischemia. These must be placed with extreme care. Onset of left or right ventricular dysfunction, or sudden appearance of ventricular arrhythmias, should raise suspicion of compromise of coronary flow.

• The seriousness of coronary button bleeding warrants extreme efforts to produce a hemostatic anastomosis with the initial construction. This is the reason we use a Teflon felt washer always around the left button and often on the right button. We tighten and re-tighten. Before proceeding to the distal graft anastomosis, we inspect each button from inside the graft very carefully, adding an extra fine suture from the inside access for any spot that even “looks at us funny.”

• Because the potential for bleeding after the Bentall procedures is very real, creative cardiac surgeons have developed technical modifications aimed at decreasing the likelihood of bleeding, especially from the proximal graft anastomosis. Some of these techniques are represented in the References for this section. One useful method, especially for surgeons starting out their independent Bentall experience, has been contributed by Dr. Bortolotti from Italy [6]. He leaves a small rim of aortic wall tissue proximally, which he then sews to the cuff of the valved conduit, providing a second hemostatic layer (see Fig. 52.9). We used this years ago while building our experience. Currently, we simply construct every anastomosis with extreme care, without any of the supplemental reinforcing techniques.

Fig. 52.9

Bortolotti’s method of preemptive reinforcement of the proximal suture line. Panel a: Note (arrow) 5 mm cuff of aortic wall that is preserved. Panel b: Cuff is sutured (running suture) to the cuff of the valved conduit, as a supplementary hemostatic layer. (Reproduced with permission from Bortolotti U. Avoiding bleeding in the modified Bentall procedure. AORTA (Stamford). 2020)

• CG: There seems to be a wide variety in the size of the coronary button and the hole in the graft for the button. Is there a general size you recommend? How much tissue should I leave on the coronary button cuff?

• JAE: I have noticed that also in my travels, Courtney. I recommend a cuff of 6-8 mm, with about a 1.2–1.6 cm opening in the graft. You want to have enough cuff on the button to sew securely, but not so much that you encourage late aneurysmal deterioration of the button itself. Above all, be careful not to “bunch up” too big a cuff in too small an opening, which can impede coronary artery flow, with disastrous results.