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Clinical Experience with the Bentall Procedure: 28 Years

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Clinical Experience with the Bentall Procedure: 28 Years http://dx.doi.org/10.3349/ymj.2012.53.5.915 Original Article pISSN: 0513-5796, eISSN: 1976-2437 Yonsei Med J 53(5):915-923, 2012 Clinical Experience with the Bentall Procedure: 28 Years Hyun-Chel Joo, Byung-Chul Chang, Young-Nam Youn, Kyung-Jong Yoo, and Sak Lee Department of Thoracic and Cardiovascular Surgery, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea. Received: February 29, 2012 Purpose: We retrospectively analyzed 28 years of experience with the Bentall pro- Revised: April 9, 2012 cedure in patients with aortic valve, aortic root, and ascending aortic disease. Ma- Accepted: April 23, 2012 terials and Methods: Between March 1982 and December 2010, a total of 218 Corresponding author: Dr. Sak Lee, patients underwent the Bentall procedure using a composite valved conduit. The Department of Thoracic and Cardiovascular “inclusion technique” was used in 30 patients (13.8%), the “open-button tech- Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, nique” in 181 patients (83.0%), and the Cabrol technique in 7 patients (3.2%). Re- Seoul 120-752, Korea. sults: The early mortality rate was 5.5% (12/218). The mean follow-up duration Tel: 82-2-2228-8488, Fax: 82-2-313-2992 was 108.0±81.0 months (range: 1-329 months). Seven patients required re-opera- E-mail: [email protected] tion, and 1 patient required stent graft insertion at the descending thoracic aorta for progression of aortic arch or descending thoracic aortic dissection or aneurysm af- ∙ The authors have no financial conflicts of interest. ter the first operation, and 5 of them had Marfan syndrome. Kaplan-Meier estimat- ed survival rates at 1, 5, 10, 20, and 25 years were 90.4%, 82.7%, 77.6%, 65.3%, and 60.3%, respectively. Freedom from reoperation rates at 1, 5, 10, 20, and 25 years were 99.0%, 98.3%, 95.5%, 90.8%, and 90.8%, respectively. Conclusion: In our experience, the Bentall procedure provided optimal survival with improved functional status. The disease of the aorta may progress, especially in patients with Marfan syndrome. Therefore, careful follow-up with regular computed tomogra- phy angiograms should be performed in these patients. Key Words: Annuloaortic ectasia, marfan syndrome, bentall procedure INTRODUCTION Since Bentall and De Bono1 first described composite valve graft implantation in 1968, this well documented technique of aortic root replacement has been used for a large spectrum of various pathologic conditions involving the aortic valve, aortic root, and ascending aorta.2-4 In this study, we retrospectively reviewed and evaluat- ed the early and long-term results of our 28-year clinical experience with the Ben- tall procedure for various aortic diseases in 218 patients. © Copyright: Yonsei University College of Medicine 2012 This is an Open Access article distributed under the MATERIALS AND METHODS terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/ licenses/by-nc/3.0) which permits unrestricted non- commercial use, distribution, and reproduction in any Patients’ characteristics medium, provided the original work is properly cited. From March 1982 to December 2010, a total of 218 patients underwent the Ben- Yonsei Med J http://www.eymj.org Volume 53 Number 5 September 2012 915 Hyun-Chel Joo, et al. tall procedure using a composite valved conduit in Yonsei type II: 18), and annular endocarditis (9). The causes of aor- Cardiovascular Center, Yonsei University Health System. tic disease included Marfan syndrome in 102 patients Our study was conducted with the approval of the Institu- (46.8%), atherosclerosis in 64 patients (29.4%), congenital tional Review Board of Yonsei University College of Medi- bicuspid aortic valve in 39 patients (17.9%), bacterial endo- cine (Yonsei Institutional Review Board No. 4-2011-0062). carditis in 9 patients (4.1%), syphilitic aortitis in 3 patients Individual patient consent was waived. The mean patient (1.4%), and Takayasu arteritis in one patient (0.5%). Twenty age at the time of the operation was 44.4±13.9 years (range, patients (9.8%) had previously undergone surgical interven- 13-76 years). Of these patients, 151 (69%) were male and tion on the aortic valve or ascending aorta, or both. Nine pa- 67 were female (31%). The preoperative diagnoses included tients (4.1%) were in New York Heart Association (NYHA) annuloaortic ectasia (144), acute aortic dissection (DeBakey functional class I, 92 patients (42.2%) in class II, 89 pa- type I: 29, type II: 9), chronic aortic dissection (type I: 12, tients (40.8%) in class III, and 28 patients (12.8%) in class IV (Table 1). Table 1. Baseline Patient Characteristics Characteristics n (%) Surgical techniques Age (yrs)±SD 44.35±13.9 Male/Female 151/67 (69.3/30.7) The operation was performed through a standard median Hypertension 64 (31.2) sternotomy, and cardiopulmonary bypass was instituted by Diabetes mellitus 9 (4.4) cannulation of the ascending aorta, aortic arch, femoral ar- CAOD 10 (4.9) tery, or subclavian artery, and the right atrium. Myocardial COPD 21 (10.2) protection was achieved by antegrade, retrograde, or simul- Old CVA 11 (5.4) taneously antegrade and retrograde intermittent cold hyper- Previous cardiac operation 20 (9.8) kalemic blood cardioplegia. The “inclusion technique” was Chronic renal failure 5 (2.5) performed in 30 patients (13.8%), the “open-button tech- NYHA class nique” in 181 patients (83.0%), and the Cabrol technique in I 9 (4.1) II 92 (42.2) 7 patients (3.2%). In patients treated with “open-button tech- III 89 (40.8) nique”, coronary reimplantation suture lines were reinforced IV 28 (12.8) with an autologous pericardial strip or removed aortic wall. Aortic pathology The Cabrol technique was used only in cases of reoperation Annuloaortic ectasia 144 (66.0) because of difficulty with mobilizing and approximating Dissection coronary arteries to the vascular graft. Acute 35 (16.3) The concomitant procedures included graft replacement Chronic 30 (13.8) of the ascending aorta (9); hemi arch (11), total arch (7), or Marfan syndrome 102 (46.8) mitral valve replacement (4); mitral annuloplasty (14), cor- Bicuspid aortic valve 39 (18.1) Maximum diameter of ascending onary artery bypass grafting (21); repair of a ventricular 56.68±19 aorta, mm±SD septal defect (4); tricuspid valve repair (10); myectomy (2); Combined mitral valve disease 46 (21.1) and the Dor procedure (1). In cases of arch or hemi arch re- AR grade placement, cerebral protection was obtained with deep hy- I 11 (5.0) pothermic circulatory arrest (DHCA) in 3 patients, DHCA II 25 (11.5) and retrograde cerebral perfusion in 8 patients, and ante- III 85 (38.9) grade cerebral perfusion through the right subclavian artery IV 97 (44.5) with moderate systemic hypothermia in 7 patients. LVEF (%) 54.3±13.1 LVESD, mm±SD 50.9±12.4 A Bjork-Shiley composite graft prosthesis (Shiley, Inc., LVEDD, mm±SD 69.2±12.4 Irvine, CA, USA) was used in 11 patients; a St. Jude com- Emergency 21 (9.6) posite graft (St. Jude Medical, Inc., St. Paul, MN, USA) in n, number; CAOD, coronary artery occlusive disease; COPD, chronic 146 patients; a Carbomedics composite graft (Carbomed- obstructive pulmonary disease; CVA, cerebrovascular accident; NYHA, ics, Inc., Austin, TX, USA) in 52 patients; ATS (ATS Medi- New York Heart Association; AR, aortic regurgitation; LVEF, left ventricular cal, Inc., Minneapolis, MN, USA) in 1 patient; freestyle ejection fraction; LVESD, left ventricular end systolic diameter; LVEDD, left ventricular end diastolic diameter; SD, standard deviation. stentless valve (Medtronic, Inc., Minneapolis, MN, USA) 916 Yonsei Med J http://www.eymj.org Volume 53 Number 5 September 2012 Experience of the Bentall Procedure in 5 patients; and aortic homograft in 3 patients (Table 2). RESULTS Follow-up and statistical analysis All patients were followed in the outpatient department with Hospital mortality and morbidity clinical examination, computed tomography scans and The overall early mortality rate, defined as death within 30 transthoracic echocardiography. When necessary, patients days of initial hospitalization, was 5.5% (12/218). Causes were interviewed via the telephone to obtain actualized in- of death were low cardiac output syndrome in 3, ventricular formation. Among 206 hospital survivors, 196 (95.1%) pa- arrhythmia in 3, pneumonia or acute respiratory distress tients were available for follow-up (mean: 108 months). Sta- syndrome in 2, sepsis in 2, cerebrovascular accident in 1, tistical analysis was performed with the SPSS 11.0 statistical and bleeding in 1 patient (Table 3). Early complications in- software package (SPSS, Chicago, IL, USA). Continuous cluded re-exploration for bleeding in 21, acute renal failure variables were expressed as the mean±standard deviation, in 20, low cardiac output syndrome in 12, upper gastroin- and compared with unpaired two-tailed t-test. Categorical testinal bleeding in 7, myocardial infarction in 4, prolonged variables were analyzed with the χ2 test or Fisher’s exact mechanical ventilation in 10, pericardial effusion in 7, tran- test, where appropriate. Univariate and multivariate analy- sient ischemic attack in 1, cerebral infarction in 1, and su- sis of predictors for early and late mortality were performed perficial wound infection in 7 patients (Table 4A). using a logistic regression model. A p-value of <0.05 was Postoperative left ventricular end-systolic dimension signif- considered statistically significant. Survival curves were icantly decreased from 50.9±12.4 to 43.1±11.4 mm (p< constructed using the Kaplan-Meier method and compared 0.001), and left ventricular end-diastolic dimension signifi- with the log-rank test. cantly decreased from 69.2±12.4 to 57.3±11.1 mm (p< 0.001). The postoperative NYHA functional class also im- Table 2.
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