Bentall and Hemiarch Replacement: Technical Nuances of a Continuous Suture Technique

The Bentall procedure with hemiarch replacement utilizing a continuous suture technique for the proximal anastomosis offers significant advantages in complex aortic surgery. This method allows for faster and more efficient anastomosis, reducing ischemic and cardiopulmonary bypass times. The continuous suture line provides uniform tension distribution, enhancing the security of the anastomosis and minimizing the risk of bleeding. It also facilitates better adaptation of the graft to the native tissue. Overall, this technique enhances operative efficiency and outcomes without compromising the durability or safety of the repair. 

A 54-year-old female patient presented with complaints of progressive exertional dyspnea for one year and a history of two episodes of presyncope in the last two months. 

She had been experiencing fatigue, reduced exercise tolerance, and occasional palpitations for the past six months. She was known to have hypertension and was on medications. 

On examination, her height was 155 cm, and her weight was 43 kg (BSA: 1.36 m²). She had a blood pressure of 140/65 mm Hg and a regular pulse rate of 78 beats per minute, exhibiting the pulsus parvus et tardus type, with a normal breathing pattern and saturation. A systolic thrill was noticed in the right second intercostal space, along with a late-peaking systolic ejection murmur at the right upper sternal border, radiating to the carotids. 

Echocardiography revealed severe calcific aortic stenosis with a peak gradient across the aortic valve of 81 mm Hg and a mean gradient of 56 mm Hg, along with a dilated ascending aorta and good ventricular function. 

A CT aortogram further showed a dilated root, ascending aorta, and arch with the following dimensions: 

Perfusion Strategy 

Bicaval venous drainage with perfusion via the innominate artery, left common carotid artery, and as needed, the left subclavian artery through the arterial limbs of the cardiopulmonary bypass (CPB) circuit was planned. 

An 8 mm Dacron graft was sutured to the proximal innominate artery and connected to 3/8-inch tubing. This tubing was attached to the 3/8-inch Y connection of the arterial circuit, which included a 3/8-inch, 3/8, and ¼-inch connector. A ¼ -inch limb was connected to the ¼ -inch side of the Y connector to supply two additional ¼ -inch limbs that perfused the left common carotid artery and left subclavian artery. 

CPB was initiated through the brachiocephalic arterial cannula and bicaval venous drainage. The ascending aorta was clamped, and cardioplegia was delivered. The diseased ascending aorta was excised, and a valved conduit was anastomosed proximally, followed by coronary button anastomosis. A lower-body circulatory arrest was performed, and the left common carotid artery was cannulated and connected to a 1/4-inch tube of the arterial limb and snugged. Antegrade cerebral perfusion was continued and monitored via near-infrared spectroscopy (NIRS). 

The distal end of the valved conduit was anastomosed to the proximal arch. The left common carotid cannula was removed just before completing the distal anastomosis while perfusion through the innominate limb was continued. After weaning off and decannulation, the 8 mm graft was cut and sutured close to the anastomotic site. 

Surgical Procedure 

The dilated ascending aorta and arch were assessed, along with the extent of the aneurysm. The innominate artery was connected to the 3/8-inch limb of the arterial circuit through an 8 mm Dacron graft. Two 1/4-inch limbs were prepared to cannulate the right common carotid artery and right subclavian artery. 

The ascending aorta was dissected circumferentially and clamped. A right superior pulmonary vein (RSPV) vent was inserted, and aortotomy was performed. Ostial cardioplegia was delivered, and commissural and aortic wall stay sutures were placed. The calcified aortic valve was excised, revealing a bicuspid aortic valve with fused left and non-commissural cusps. The left coronary button was harvested, followed by the creation of the right coronary button, with a stay suture placed on the right coronary button. The excess intervening ascending aortic tissue was excised, and the aortic annulus was delineated and dissected. The annulus was sized, and the annular suture line was marked. 

An appropriately sized mechanical prosthetic valve was sutured to a Dacron tube graft that was 3 mm larger. The first proximal valved conduit suture was placed in a forehand manner on the sewing ring, followed by a backhand bite on the left coronary cusp (LCC) annulus using a 2-0 26 mm Prolene suture. Continuous suture bites were taken, moving toward the right coronary cusp (RCC) and non-coronary cusp (NCC) commissure with equal spacing. Another suture was placed starting from the LCC and RCC commissure, running toward the RCC and NCC commissure. 

The valved conduit was lowered, and the loops of the continuous sutures were gently tightened using a blunt-tipped nerve hook. The sutures were tied, and the anastomotic line was reinforced with another Prolene suture to ensure hemostasis. 

An appropriately positioned opening in the aortic graft was created directly opposite the left coronary ostium using a battery-operated cautery device. The left coronary button was anastomosed in a tension-free manner using a 5-0 16 mm Prolene suture. A similar anastomosis was performed between an opening in the anterior part of the graft and the right coronary button. The length of the proximal part of the right coronary artery and the position of the anastomosis on the graft were carefully considered to ensure long-term patency. 

The patient was further cooled, lower-body circulatory arrest was initiated, the aortic clamp was released, and perfusion limbs were placed into the left carotid artery and left subclavian artery ostia and snugged. Antegrade perfusion was started to ensure complete cerebral and spinal protection. 

Redundant aortic tissue from the distal ascending aorta and arch along the lesser curvature was excised. The left common carotid artery was cannulated and snugged. The distal aorta was reinforced with Teflon felt bits internally and a rim of Teflon felt strip externally. This provided adequate strength to the suture line and ensured it was leak-proof.  

The distal end of the valved conduit was appropriately sized, and the distal aorta-to-graft anastomosis was initiated posteriorly and continued anteriorly using a 4-0 26 mm Prolene suture. Each bite was meticulously placed to ensure adequate depth and uniform spacing. Just before completing the anastomosis, the common carotid artery cannula was removed, and the artery was snugged before finalizing the anastomosis after proper de-airing.  

A well-seated graft with a good lie was observed after rewarming, weaning, and decannulation. 

Postoperative echocardiography showed a well-functioning prosthetic valve with no significant gradients across it and good ventricular function. 

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