European Journal of Cardiovascular Medicine

Since its original description by Bentall and De Bono in 1968 [1], composite aortic root replacement has become the standard surgical treatment for patients with combined aortic valve and ascending aortic pathology. Advances in surgical technique, myocardial protection, and prosthetic valve technology have significantly improved outcomes over the past decades [2,3].

Current ACC/AHA and ESC guidelines recommend aortic root replacement in patients with aortic root aneurysm associated with significant valve disease, connective tissue disorders, and selected cases of acute type A aortic dissection [6,7]. Although valve-sparing root replacement has gained popularity in selected patients, the Bentall procedure remains widely practiced due to its reproducibility and applicability in patients with severe valve pathology, infective endocarditis, and emergency presentations [4,8].

This retrospective single-center observational study included all adult patients who underwent Bentall procedures between January 2014 and December 2024. Institutional ethics committee approval was obtained, and the requirement for individual informed consent was waived owing to the retrospective nature of the study. Patient demographics, comorbidities, imaging findings, operative details, perioperative complications, and follow-up outcomes were extracted from hospital records and surgical databases. Surgical Technique All procedures were performed via median sternotomy under general anesthesia. Standard aortic and right atrial cannulation was employed in elective cases without arch involvement. In patients with extensive ascending aortic pathology, anticipated circulatory arrest, or acute type A aortic dissection, an extra-anatomic cerebral perfusion strategy was routinely utilized. A 6–8 mm ringed polytetrafluoroethylene (PTFE) graft was anastomosed end-to-side to the right subclavian artery through an infraclavicular incision. The graft was cannulated and connected to the arterial limb of the cardiopulmonary bypass circuit, allowing continuous antegrade cerebral perfusion during cooling, hypothermic circulatory arrest when required, and rewarming [9–11]. Systemic cooling to moderate hypothermia (24–28°C) was used when circulatory arrest was required. Myocardial protection was achieved using cold blood cardioplegia administered via antegrade and retrograde routes. The diseased aortic root and valve were excised, a composite valved conduit was implanted at the level of the aortic annulus, coronary buttons were reimplanted, and distal graft anastomosis was completed following re-establishment of systemic perfusion. Fig 1 and 2: –8 mm ringed polytetrafluoroethylene (PTFE) graft anastomosed end-to-side to the right subclavian artery through an infraclavicular incision Fig 3 and 4: Aortic root and ascending aorta aneurysm with aortic valce exposed after opening aneurysmal segment Fig 5 and 6: Ethibond sutures taken on the valve and Bentall’s conduit being lowered into the valve Fig 7: Bentall’s conduit sutured to the aortic valve

Table 1. Baseline Characteristics

Table 2. Indications for Surgery

Table 3. Operative and Early Outcomes

This ten-year single-center case series provides a comprehensive assessment of contemporary outcomes following the Bentall procedure and reinforces its continued relevance in the management of complex aortic root pathology [4,5]. Despite increasing interest in valve-sparing techniques, composite aortic root replacement remains a definitive and reproducible operation, particularly in patients with significant valve pathology, connective tissue disorders, infective endocarditis, and emergency presentations [8,12].

The demographic profile and disease spectrum observed in our cohort are consistent with those reported in major institutional series [12,13]. The predominance of aortic root aneurysm with severe aortic regurgitation reflects the natural history of progressive root dilation leading to annular enlargement and cusp malcoaptation [6,7].

Emergency surgery for acute type A aortic dissection remains associated with increased operative risk. In our series, early mortality occurred exclusively in this subgroup, emphasizing the impact of preoperative status rather than operative technique alone [8,14].

A key technical feature of our approach was the use of right subclavian artery cannulation via a PTFE graft for antegrade cerebral perfusion. This strategy has been shown to reduce embolic stroke and improve neurological outcomes in complex aortic surgery [9–11]. The low incidence of neurological complications in our series supports the effectiveness of this cerebral protection strategy.

Valve selection was individualized. Mechanical composite grafts were preferentially used in younger patients for durability, whereas bioprosthetic grafts were selected in older patients or those with contraindications to anticoagulation, in accordance with contemporary guideline recommendations [6,15]. At mid-term follow-up, survival was excellent, with no reoperations on the aortic root or valve, underscoring the durability of the Bentall procedure.

Valve-sparing aortic root replacement offers advantages in selected patients but is technically demanding and associated with a learning curve and risk of late aortic regurgitation [16,17]. Our experience supports the continued role of the Bentall procedure as the operation of choice in patients unsuitable for valve-sparing approaches.

Limitations of this study include its retrospective design, small sample size, and single-center nature.

The Bentall procedure remains a safe, effective, and durable solution for complex aortic root pathology. With meticulous surgical technique and modern cerebral protection strategies, excellent early and mid-term outcomes can be achieved.

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