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 Table of Contents  
Year : 2019  |  Volume : 17  |  Issue : 1  |  Page : 75-78

Comparison study between bentall operation and valve-sparing procedures

1 Department of Cardiothoracic Surgery, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Cardiothoracic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission28-Jan-2019
Date of Acceptance10-Apr-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Mohamed Abdel Hafez Fouly
MD Cardiothorathic, Lecturer of Cardiothorathic Surgery, Cairo University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_18_19

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Background The best solution for management of cases presented with aortic aneurysm still presents a lot of debate.
Objectives To compare between Bentall operation and valve-sparing procedures in different cases of aortic aneurysm.
Patients and methods The study included 45 patients who underwent the aortic root operation either Bentall operation (group A=30 patients) or Tirone David operation (group B=15 patients). Comparison between the two groups was done in several preoperative, intraoperative, and postoperative data.
Conclusion Bentall is preferred than Tirone David for patients who undergo aortic root operation.

Keywords: aortic root operation and Aortic aneurysm, bentall, Tirone David

How to cite this article:
Ghalwash MM, Fouly MH. Comparison study between bentall operation and valve-sparing procedures. Al-Azhar Assiut Med J 2019;17:75-8

How to cite this URL:
Ghalwash MM, Fouly MH. Comparison study between bentall operation and valve-sparing procedures. Al-Azhar Assiut Med J [serial online] 2019 [cited 2021 Jun 14];17:75-8. Available from: http://www.azmj.eg.net/text.asp?2019/17/1/75/266733

  Introduction Top

Aortic aneurysms are the 13th leading cause of mortality in United States. The incidence of thoracic aortic aneurysms is estimated to be 5.9 cases per 100 000 person years, and the incidence appears to be increasing as a result of routine screening studies, improved imaging modalities, and increasing clinical awareness [1]. Aortic root pathologies involving the aortic valve and ascending aorta in adults, predominantly including aortic aneurysms and type A dissections, have a yearly incidence of 10.4 and 2 per 100 000, respectively [2]. Optimal function of the aortic root depends on the structural integrity of its constituent parts: the valve, the annulus, the sinuses of valsalva, and the sinotubular junction [3]. This complexity has prompted us to perform total aortic root replacement with coronary artery reimplantation in patients with aortic valve or root disease [4]. ECG evaluation of aortic insufficiency is also a frequent mode of diagnosis, in between 25 and 75% of patients [5]. Transesophageal ECG is a portable diagnostic tool aiding diagnosis of acute aortic pathologies in emergency departments, operating room, and clinical suite [6]. Aortography provides precise delineation of the aortic lumen, and certain diseases have very characteristic arteriographic patterns [7]. Contrast-enhanced computed tomography (CT) is the most widely used noninvasive technique for imaging the thoracic aorta. CT scanning provides rapid and precise evaluation of the ascending aorta in regard to size, extent, and location of the disease process. CT scanning detects areas of calcification and accurately identifies dissections and mural thrombus [8]. Replacement of the aortic root and ascending aorta is usually the treatment of choice to prevent progressive dilatation, aortic insufficiency rupture, and death [4]. Subsequent modifications helped surgeons avoid tension on the button coronary anastomosis, preventing excessive bleeding and kinking of the coronary arteries and decreasing operation times [9].

  Patients and methods Top

Between January 2014 and September 2017, 45 patients who underwent aortic root operation for aortic aneurysm using either Bentall operation or valve-sparing procedure in our hospital were included.

Inclusion criteria

The following were the inclusion criteria:
  1. Patients with aortic root 5.5 cm or more and severe aortic regurge.
  2. Patients with Marfan syndrome.
  3. Patients with aortic stenosis with severe poststenotic dilatation.
  4. Patients with pseudoaneurysm of ascending aorta.
  5. Patients who underwent ascending aorta replacement or root replacement owing to intraoperative events.

Exclusion criteria

The following were the exclusion criteria:
  1. Patients with arch or descending aortic aneurysm.
  2. Patients with acute or chronic aortic dissection.


  1. Group A patients included 30 patients who underwent Bentall operation.
  2. Group B patients included 15 patients who underwent valve-sparing procedure.

Operative techniques

The femoral artery is exposed and prepared for urgent cannulation. The standard approach for aortic root replacement is through median sternotomy, and surgery is performed under cardiopulmonary bypass. Mobilization the aortic arch and dissection of the aorta beyond the pericardial reflection is done, as well as application of a tap around the ascending aorta so that a high cannulation of the aortic arch can be performed.

Arterial cannulation

The preferred site of cannulation for cardiopulmonary bypass is usually in the distal ascending aorta. Alternative cannulation sites are the femoral artery and axillary artery.

Venous cannulation

A large single two-stage venous cannula is inserted in the right atrium.

Bentall protection

  1. The aneurysm is opened and the aortic valve is excised.
  2. The sewing ring of the graft valve prosthesis is sutured to the aortic annulus with interrupted pledged mattress sutures of 2-0 braided polyester.
  3. A hand-held, battery-operated eye cautery is used to create an 8-mm diameter hole in the composite graft at an appropriate level from the annulus such that the mobilized coronary arteries.
  4. The left coronary button is anastomosed first.
  5. The right coronary is then anastomosed later.
  6. The distal end of the composite graft is cut to appropriate length and is sutured to the completely transected distal ascending aorta using a continuous 4-0 polypropylene suture, incorporating a strip of Teflon felt.
  7. The aortic clamp is then removed and deairing occurred through the cannula of cardioplegia. When rewarming is complete and strong cardiac contractions have resumed, air is evacuated from the left atrium and left ventricle, the left ventricular vent is removed, and cardiopulmonary bypass is discontinued. After decannulation, administration of protamine sulfate and careful examination of all suture lines should be conducted systemically.

Reimplantation of coronary arteries

A right angle clamp is introduced inside Dacron tube just above prosthetic valve and then approximate left coronary button from outside. Pen hole is created in the Dacron tube in proper position and is reanastomosed with 6-0 prolene suture in a continuous manner. The same technique is used in reimplantation of right coronary button.

Tirone David

Dissection of the aortic root from outside from right atrium and right ventricular outflow tract till the level under the aortic valve leaflets and then removal of aneurysmally part of ascending aorta was performed. The right and left coronary buttons are dissected and left in place and suspended with 5-0 prolene sutures. Reimplantation of the aortic valve within a Dacron tube graft is done. The Dacron tube graft is attached to the aortic root base with pledgeted sutures placed from underneath the leaflet attachments. The valve commissures are re-suspended inside the aortic tube graft, thereby reconstructing the semilunar leaflets inside the tube graft. The operation is completed by attaching the coronary buttons to neo-sinuses and suturing of the distal conduit anastomosis, thus establishing a more normal diameter for the ascending aorta. The remnant of aortic wall and commissures are sutured with Dacron tube in a continuous manner.

  Results Top

Results were obtained by using statistical analysis program SPSS 15 (IBM Corp., Chicago, USA) during the study. Forty-five patients were enrolled in the study and divided into two groups; the data of both groups were compared with the following results:

There was a statistically significant difference between the two groups in most of the risk factors and preoperative data ([Table 1]).
Table 1 Comparing the studied groups regarding preoperative data

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Group I mean age was 39.4±5.5 years, whereas group II mean age was 47.0±7.6 years (P0.001). As younger age patients had mostly rheumatic etiology, they were less amenable for valve-sparing procedure. There were five (16.7%) females in group I, whereas group II had two (13.3%) females.

Group I had 20 patients with hypertension, whereas group II had 14 with hypertension (P=0.018) showing predominance in the second group.

In group I, ejection fraction (EF) was 56.6±6.32 and end diastolic dimension (ED) was 6.02±0.40, showing more poor function and less amenable for valve sparing, whereas in group II, EF was 61.3± 3.50 and ED was 5.41±0.16 (P=0.011 and <0.001, respectively).

Operative results

In group I, time of operation was 151.7±17.3 min, whereas in group II, it was 266.5±25.7 min, with significant statistical difference (P<0.011) ([Table 2]).
Table 2 Comparing the studied groups regarding operative data

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Postoperative results

Bleeding in group I was 438.3±63.29 ml in 24 h, whereas in group II were 601.4±47.62 ml in 24 h (P<0.001).

Group I had three (10.0%) cases that needed blood transfusion, whereas in group II, four (26.7%) cases needed blood transfusion (P=0.379).

There was no significant difference in hemoglobin level between group I (10.27± 0.651 g/dl) and group II (9.981±0.618 g/dl) (P=0.260).

One case in group I (3.3%) showed postoperative wound infection versus group II had three (20%) cases.

Hospital stay in group I was 5.06±1.27 days, whereas in group II was 7.53±0.517 days (P<0.001) ([Table 3]).
Table 3 Bentall and valve-sparing procedures according to outcomes

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Regarding the rate of postoperative bleeding and reopening together with postoperative stay in the ICU and total hospital duration, there were no statistical significances.

In group I, no aortic regurgitation was detected, postoperative EF was 51.2±4.82, and postoperative ED was 5.95±0.35.

In group II, four (28.5%) cases showed moderate aortic regurgitation, postoperative EF was 55.6±3.77, and postoperative ED was 5.39±0.16.

There were statistically significant differences between the two groups.

There was no statistical difference between the two groups regarding the mortality, with two (6.7%) cases in group I and one (6.7%) case in group II.

  Discussion Top

This study included 45 patients, where 30 of them underwent complete aortic root replacement by Bentall technique with direct coronary reimplantation and the other 15 patients underwent valve-sparing procedure by Tirone David.

David and colleagues present a study from 1988 till 2010 for aortic root aneurism, where patients underwent valve-sparing procedure. It included 371 patients aged 47±15 years, with left ventricular ejection fraction (LVEF) more than 60% in 71.2% of cases, cardiopulmonary bypass time was 141±32 min, aortic cross-clamp time was 102±24, bleeding postoperatively was seen in 9.1%, postoperative ECG showed freedom of aortic regurge in the first year (99.7±0.3%), and the mortality was four (1.07%) cases [10].

Leontyev and colleagues present a study that included 179 patients aged 49±15.1 years who underwent aortic valve-sparing operation from 2003 to 2011 for aortic root aneurysm, with LVEF of 58±8.8%, cardiopulmonary bypass time of 196±104 min, aortic cross-clamp time of 126±54, bleeding postoperatively in 8.9%, and postoperative ECG showed complete freedom of aortic insufficiency in the first year but after 5 years freedom was 93.6±2.1%, and in their study, mortality was seen in two (1.1%) cases [11].

Kvitting and colleagues present a study including 233 patients who underwent aortic valve-sparing procedure for aortic root aneurism from 1993 to 2009, with LVEF of 61%, cardiopulmonary bypass time of 265 min, aortic cross-clamp time of 211 min, the freedom of aortic valve insufficiency at 5 and 10 years was 97.6±1.4 and 96.1± 2.1%, respectively, and two cases mortality (0.9%), where one death was from right ventricular failure and the second death was from CNS cerebral infarction [12].

Vendramin and colleagues in their study included 77 patients aged 55.2±12.7 years, who underwent elective Bentall operation from 1994 to 2010 for chronic aortic root aneurysm with bicuspid aortic valve disease, where cardiopulmonary bypass time was 201.5±56.4 min, aortic cross-clamp time was 195±86 min, and mortality was 2.6% for cardiac insufficiency [13].

Djokic et al. [14] in their study included 90 patients aged 54±10 years, who had undergone surgery from 1997 through 2003 for chronic ascending aortic aneurysm and significant aortic regurgitation. Overall, 2.2% of these cases reopened owing to bleeding, and mortality was 2.2% owing to acute heart failure or stroke.

  Conclusion Top

Our results were comparable to internationally published papers, with some concerns about the strategies of patient diagnosis, patient selections, and the available complex procedures with variable facilities during operation and postoperatively in the developed countries.

Bentall results are preferred than Tirone David according to our facilities as there is no aortic regurgitation.

Our study has limitations because the recorded data must include late postoperative results, especially for Bentall operation, where there is prosthetic valve, which needs long-term follow-up for its complications with the anticoagulant drugs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bickerstaff L, Pairolero P, Hollier L. Thoracic aortic aneurysms: a population-based study. Surgery 1982; 92:1103.  Back to cited text no. 1
Cherry C, Debord S, Hickey C. The modified Bentall procedure for aortic root replacement. AORN J 2006; 1:52–70.  Back to cited text no. 2
Lankipalli RS, Pellecchia M, Burke JF. Magnetic resonance angiography in the evaluation of aortic pseudo aneurysm. Heart 2002; 87:157.  Back to cited text no. 3
Pibarot P, Dumesnil J. The relevance of prosthesis-patient mismatch after aortic valve replacement. Nat Clin Pract Cardiovasc Med 2008; 5:764–765.  Back to cited text no. 4
Kadolitsch K, Kojico D, Oezsoeza M, Brucknerb T, Karcka M. Treatment of ascending aortic aneurysms using different surgical techniques:a single-centre experience with 548 patients. Eur J Cardio-Thorac Surg 1998; 44:337–345.  Back to cited text no. 5
Schappert JD, Miller DC. A simple trick for repairing coronary pseudo aneurysm complicating a Bentall operation. Ann Thorac Surg 1994; 74:268–270.  Back to cited text no. 6
Guthaner D. Angiography in assessing aneurysms and dissecting hematomas of thoracic aorta,in Taveras JN,Ferrucci JT(eds):Radiology:Diagnosis-Imaging-Intervention. Philadelphia: JB Lippincott; 1994; 62:421–466  Back to cited text no. 7
Setser R, Sayre K, Flacke S. Assessment of ventricular contractility during cardiac magnetic resonance imaging examination using normalized maximal ventricular power. Ann Biomed Eng 2001; 29:974.  Back to cited text no. 8
Yakut C. A new modified Bentall procedure:the flanged technique. Ann Thorac Surg 2001; 71:2050–2052.  Back to cited text no. 9
David TE, Selke F, Swanson S, Nido PJ. Surgery of the aortic root and ascending aorta. In: seventh edition of Sabiston and Spencer.Surgery of the chest. Philadelphia: Elsevier Saunders 2014; 7:1115–1135.  Back to cited text no. 10
Leontyev KS, Grande J, David TE, Verrier E. Aortic root and valve relationships: impact on surgical repair. J Thoracic Cardiovasc Surg 2011; 107:162–170.  Back to cited text no. 11
Vendramin I, Meneguzzi M, Sponga S, Livi U. Bicuspid aortic valve disease and ascending aortic aneurysm:should an aortic root replacement be mandatory? Eur J Cardio-Thorac Surg 2015; 49:1–7.  Back to cited text no. 12
Kvitting MG, Wiegers SE, Sutton J. Bicuspid aortic valves are associated with aortic dilatation out of proportion to coexistent valvular lesions. Circlation 2013; 102:35–39.  Back to cited text no. 13
Djokic O, Tomic S, Djukanovic B. Effect of elective Bentall procedure on left ventricular systolic function and functional status;long-term follow-up in 90 patients. Tex Heart Inst J 2016; 43:114–118.  Back to cited text no. 14


  [Table 1], [Table 2], [Table 3]


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