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The aorta is considered the largest blood vessel in our body. It is responsible for carrying blood and various other essential nutrients from the heart to different other parts of the body. The Bentall procedure is a form of open heart surgery performed to treat the issues related to the aorta, primarily involving the aortic root and valve, which takes place due to aortic aneurysms.
An aortic aneurysm is a medical condition characterised by a bulge in the walls of the aorta. In severe cases, these aneurysms either burst or even split, causing internal bleeding or blockage of blood flow from the heart to various other organs. At this point, it becomes a life-threatening condition.
Hugh Bentall and Antony De Bono, 1968, first performed the Bentall procedure. This procedure involves the composite graft replacement of the aortic valve and ascending aorta with the reimplantation of coronary arteries into the graft.
When is the Bentall Procedure Performed?
The doctors recommend this procedure to patients whenever they have problems with the aorta. Apart from that, various other conditions that can occur are as follows:
- Marfan's syndrome: This genetic condition causes various problems within the connective tissue of an individual, including the tissues in the aortic root and aortic valve.
- Aortic regurgitation: This is a condition where the aortic valve doesn't close properly.
- Aortic Aneurysm: This involves the presence of a bulge in the aorta.
- Aortic dissection: This involves a tear in the inner layer of the aorta.
- Autoimmune diseases like Takayasu arteritis
- Congenital heart disease
- Physical trauma
- Overall degeneration is caused due to smoking, high levels of blood pressure, and atherosclerosis.
How to Prepare for the Bentall Procedure
Before the surgery
- All the risks and complications associated with this procedure are to be explained to the patient.
- Various imaging scans are to be done, including Magnetic Resonance Imaging (MRI) and Computed Tomography (CT-Scan), to determine the location best suited for the placement of wires for DBS.
- Inform the doctor about any previous infection, injury, or surgery near the groin or genitals.
- Tell the doctor about the list of medications the child has, including the consumption of herbal supplements.
- Avoid intake of anti-inflammatory medications and aspirin as well because they tend to increase the risk of bleeding.
- The doctor gives instructions regarding when to shower and prepare for the procedure.
- Bentall procedure valve selection. The valves are selected from mechanical valve replacement, and valve replacement is performed with synthetic, biological material. Each of them has its advantages as well as disadvantages. The mechanical valves last long and are very durable. However, the patient has to be on anticoagulant therapy life-long to ensure that the patient doesn't develop a blood clot at the replacement site. On the other hand, synthetic biological valve replacement doesn't last long and requires follow-up surgery. However, the patient doesn't need to take anticoagulant therapy with this type of replacement.
During the procedure
- Anaesthesia: First, the patient is administered general anaesthesia during the procedure so that the patient won't feel any pain.
- Catheter and Ventilator Placement: After this, the doctor will insert a catheter to collect the urine output during and after the surgery. The patient will also have a unique tube near the airway, which will be connected to a ventilator.
- Use of Heart-Lung Bypass Machine: Once everything is ready, the surgeon will make an incision in the chest region to access the aortic valve and the aorta.
- Replacement of Aorta and Valve with Prosthetic Graft: The surgeon will then clamp the aorta and remove the damaged portions and the aortic valve, after which the surgeon will replace that part of the aorta with a prosthetic tube termed a graft. Inside this graft lies an artificial aortic valve, which can be mechanical or synthetic biological tissue.
- Joining of Graft to Remaining Aorta and Heart: The surgeon will surgically join one end of the graft to the remaining normal aorta, whereas the other end containing the valve is sewn into the heart. The doctor will also need to join the surrounding coronary arteries that help bring the blood back to the heart to ensure they receive adequate blood flow after the procedure.
- Removal of Clamp and Restoration of Blood Flow: Once everything gets sorted out, the clamp can be removed later. Then, the patient is removed from the heart-lung machine, and the heartbeat will be restored as the blood begins to flow through the artificial valve and graft and out towards the rest of the body.
- Closure of Sternum and Incision Site: Finally, the surgeon will close the sternum with the help of an incision across the region of the chest.
After the Procedure
- The patient is placed on a ventilator with an endotracheal tube and chest tubes to drain excess fluids and air after surgery.
- The patient is closely monitored overnight in the recovery room or ICU for any complications resulting from surgery, such as blood clots.
- Eating and drinking typically resume the day following surgery, with transfer to a general or private ward after a day or so in the ICU.
- Patients are monitored for bowel movements and may have catheters and chest tubes removed within a couple of days, depending on their status.
Possible Future Surgeries
Some people undergo the Bentall procedure very well and never need follow-up surgery. However, in some cases, people eventually need another surgery, as in the case of synthetic biological valve replacement.
This might also be more likely to happen if patients have Marfan's syndrome and the underlying problem causes another aneurysm to develop. In this case, patients might need some surgical repair on the aorta.
Risk Factors Associated with Bentall Procedure
As seen in various open heart surgeries, the Bentall procedure has its share of complications. The risk of various possible complications includes the following:
- Stroke
- Heart attack
- Sudden kidney failure
- Reduced cardiac output
- Infection, i.e., sepsis, pneumonia, etc.
- Internal bleeding
- Blood clots in the lungs or legs
- In rare cases, Death
Outlook of Bentall Procedure
The long-term outlook for patients undergoing this procedure is favourable, and most patients manage to return to their normal activities after the recovery phase. However, very few patients need to make lifestyle modifications such as avoiding indulging in strenuous exercises or taking certain medications.
When to contact the doctor
- The patient feels unwell a week after the procedure
- The patient is having high grades of fever above 101 degrees Fahrenheit
- The patient experiences nausea and difficulty breathing
Review
Reviewed By Dr. Rajneesh Malhotra, Vice Chairman & Head - CTVS, Cardiac Sciences, Cardiac Surgery (CTVS), Robotic Surgery on 4 June 2024.