Modified Button-Bentall Operation: The Miniskirt Technique

The aim of this video is to highlight the surgical details of a modified button-Bentall operation specifically designed to incorporate any type of prosthetic valve in composite conduit aortic root replacement. The authors’ technical modification allows composite conduit creation and proximal suture line construction as a single-step maneuver. Moreover, the proximal suture line is reinforced with a running monofilament suture incorporating aortic wall remnants and graft edge, therefore improving proximal hemostasis. In the strategy presented, the fundamental principles of a traditional aortic root replacement are respected, and meticulous surgical technique to ensure absolute hemostasis is of the utmost importance in aortic root surgery.

One of the key points in the authors’ technique for aortic root replacement is the miniskirt technique. The authors don’t use routinely valved conduits for aortic root replacement, preferring to prepare the conduit during the operation so that they can choose separately the prosthetic valve and the vascular graft.

After the implantation of the valved graft, the authors perform a continuous 4/0 polypropylene suture between the proximal part of the vascular graft and the remnant of the aortic sinuses above the annulus. This hemostatic suture has been named Miniskirt.

The patient was a 48-year-old man with a 55 mm aortic root aneurysm and a moderate to severe aortic regurgitation due to a calcified bicuspid aortic valve. After a longitudinal aortotomy, the ascending aorta was resected, the aortic valve was excised, and the coronary artery buttons were carefully prepared.  Special attention has to be made in resecting and preparing the aortic root. If possible, at least 10 mm of native aortic wall has to be left in place. Subsequently, a deep root dissection was carried out, similar to what the authors do for a David procedure. This deep dissection is crucial to expose at least 8 to 10 mm of the aortic wall, which is necessary to perform the miniskirt. The authors then started placing 2/0 pledgeted interrupted stitches all around the aortic annulus. Teflon felts were left outside the aorta. Then all the 2/0 stitches are passed first in the valve and then in the Valsalva graft. In order not to lose any additional ischemic time, if they make a comparison with the use of a commercially available readymade valved graft, they try to pass all the stitches in the valve and in the tube altogether. They have approximately 8 mm of aortic wall and the basal collar of the Valsalva graft.

The authors start the miniskirt suture. A 4/0 polipropilene with a 17 mm needle is used. Usually, they start forehand from the left-right commissure and proceed first counterclockwise. Therefore, they suture the remnant of the left sinus first. If needed, excessive aortic tissue from the top of the commissures can be removed. Then they proceed clockwise in order to finish the miniskirt.

The authors believe this technique is very important in order to obtain a safe hemostasis and to prevent the growth of late pseudoaneurysms. Coronary ostia reimplantation is the next step of the operation. A thin strip of teflon felt is used to reinforce both coronary ostia. Distal anastomosis was performed after reinforcement of the fragile aortic wall with two strips of teflon. After careful deairing, cross clamp was removed and spontaneous sinus rhythm was observed. The patient was then easily weaned off CPB. Transesophageal echocardiography confirmed a well-functioning aortic valve and a normally contracting left ventricle.

References

1. Copeland JG 3rd, Rosado LJ, Snyder SL. New technique for improving hemostasis in aortic root replacement with composite graft. Ann Thorac Surg. 1993; 55:1207-1209.
2. Michielon G, Salvador L, Da Col U, Valfrè C. Modified button-Bentall operation for aortic root replacement: the miniskirt technique. Ann Thorac Surg. 2001; 72:S1059-1064.
3. Yan TD. Mini-Bentall procedure: the “French Cuff” technique. Ann Thorac Surg. 2016; 101:780-782.

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