Aortic Root Replacement With a Bio-Bentall

This article is part of CTSNet’s Guest Editor Series, “Mastering Aortic Root Surgery—Learning From Top Surgeons”. Dr. Lorena Montes invited top cardiac surgeons from around the world to contribute clinical videos on various aortic root surgery techniques. 

This video demonstrates an 82-year-old male with chronic renal insufficiency, who was admitted for decompensated heart failure. The echocardiogram showed severe aortic regurgitation, with retraction of the cusps, a severely dilated left ventricle with 72mm of LVEDD, and an LVEF of 40 percent. His proximal aorta was aneurysmal, measuring 54 mm at the aortic root, 62 mm at the ascending root, and 45 mm at the aorta near the innominate artery.  

Given the patient´s comorbidities and overall clinical picture, an aortic root replacement with a stented bioprosthetic valve conduit and replacement of his proximal arch was decided. The patient was monitored with right radial and femoral arterial lines, near infrared spectroscopy, nasopharyngeal and rectal temperature probes, and transesophageal echocardiogram.  

After a median sternotomy was performed, arterial cannulation was then executed via an 8 mm graft onto the innominate artery. After clamping the distal ascending aorta, the aorta was transected, and ostial del Nido cardioplegia was administered. Three retractions sutures were placed on the commissures and the valve was excised. The aortic root was dissected circumferentially and the coronary buttons were mobilized. A circumferential row of 2-0 braided non-pledgeted sutures were placed circumferentially around the annulus and then passed through the sewing ring of a 27 mm valve conduit and secured in place. A secondary suture line was constructed circumferentially between the rim of aortic tissue and the sewing ring of the valve. Once the temperature reached 28°C, the pump flow was reduced to 1L and the innominate artery was clamped. The proximal arch was transected, and a 32 mm Dacron graft was anastomosed to the distal aorta just proximal to the innominate artery. Flows then resumed to the full systemic circulation, and the graft was deaired and clamped. The coronary buttons were anastomosed to their respective sinuses in the usual fashion. Cardioplegia was then delivered through the graft, and the patient was rewarmed entirely. The graft-to-graft anastomosis was then completed, the heart was deaired, and the cross-clamp was removed. The patient weaned uneventfully from cardiopulmonary bypass. 

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