Mini-Bentall procedure

Abstract

An important goal in cardiovascular and thoracic surgery is reducing surgical trauma to achieve faster recovery for our patients. Mini-Bentall procedure encompasses aortic root and ascending aortic replacement with re-implantation of coronary buttons, performed via a mini-sternotomy. The skin incision extends from the angle of Louis to the third intercostal space, usually measuring 5-7 cm in length. Through this incision, it is possible to perform isolated aortic root surgery and/or hemi-arch replacement. The present illustrated article describes the technical details on how I perform a Mini-Bentall procedure with hemi-arch replacement.

Keywords: Aortic root surgery; Bentall procedure; minimally invasive techniques.

Figure 1

A midline skin incision is performed from the manubrio-sternal junction to the level of the third intercostal space. A reversed “J” upper hemi-sternotomy is terminated to the left fourth intercostal space.

Figure 2

The mid-ascending aorta is slung with a Nylon tape. The access should adequately expose the aorta from the level of sinotubular junction to that of the distal ascending aorta.

Figure 3

Cardiopulmonary bypass is established via central aortic cannulation and femoral venous cannulation. A 16 Fr DLP pulmonary artery vent cannula (Medtronic Inc, Minneapolis, MN, USA) is inserted in the main pulmonary trunk.

Figure 4

The ascending aortic aneurysm is resected, leaving 1 cm cuff of aortic tissue proximal to the cross-clamp and 1 cm above the sinotubular junction.

Figure 5

The aortic root is carefully mobilized circumferentially and resected, leaving a rim of aortic wall just above the aortic annulus. The coronary buttons are prepared.

Figure 6

To provide an excellent exposure, the aortic root is brought in the cephalad direction by pulling on three commissural traction sutures.

Figure 7

The aortic leaflets are resected and the aortic annulus is decalcified.

Figure 8

Horizontal mattress sutures are used, with pledgets placed neatly below the aortic annulus.

Figure 9

The valve conduit is parachuted down by gently pulling the sutures vertically upwards with one hand and firmly pushing the valve conduit down onto the annulus with the other.

Figure 10

The left coronary button is trimmed, leaving a 3 mm circumferential cuff and re-implanted using a 5-0 running polypropylene suture.

Figure 11

The right coronary button is prepared and re-implanted using a 5-0 running polypropylene suture.

Figure 12

The graft is trimmed and anastomosed to the distal ascending aortic cuff by using a 3-0 running polypropylene suture.

Figure 13

The mid to distal ascending aorta is resected completely, together with the cannulation site. Selective antegrade cerebral perfusion is achieved by cannulating the innominate artery with or without left common carotid artery.

Figure 14

The open distal anastomosis is performed with a separate Ante-Flo graft with a single side arm (Vascutek Ltd, Renfrewshire, Scotland), using a continuous 3-0 running polypropylene suture.

Figure 15

A graft-to-graft anastomosis is performed using a continuous 3-0 running polypropylene suture and reinforced using pledgeted 4-0 polypropylene sutures where necessary.