Deep Dive Into Aortic Surgery: Everything You Need to Know About Mini-Bentall

An important goal in modern cardiovascular and thoracic surgery is reducing surgical trauma to achieve faster recovery for patients. More surgeons are comfortable with aortic valve replacement via upper hemi-sternotomy or right mini thoracotomy. Naturally, there is a growing interest in performing proximal aortic surgery via a minimal access incision. This video article describes the technical details of the mini-Bentall procedure for a patient with bicuspid aortic valve and aortic root aneurysm, using the “French Cuff” technique (1). 

Mini Sternotomy
The mini sternotomy is performed using a handheld electrical saw from the superior extent of the manubrium. The division is terminated to the third or fourth left parasternal space. The main advantage of doing a mini sternotomy to the left (a reverse “J”) is increasing the exposure of proximal arch, especially if a concomitant hemi-arch replacement is anticipated. This approach also provides adequate access to the right coronary annulus. 

Cannulation
Arterial cannulation can be established either via distal ascending aorta or femoral artery. It is preferable to have a central arterial cannulation whenever possible to provide adequate antegrade systemic perfusion and avoid potential retrograde embolization and vascular complications that may be associated with peripheral arterial cannulation. Peripheral venous cannulation is established first, using a Seldinger technique under transesophageal echocardiography (TEE) guidance through a bicaval view. 

Aortoscopy
Recently, the author has introduced aortoscopy in aortic surgery to assess aortic valve morphology and, more important, aortic valve competency after valve sparing root replacement. In this video article, surgeons first introduced a 10 mm 3D 4K Storz endoscopy through a small incision in the proximal ascending aorta after the aorta was clamped and the heart was arrested. Even though the preoperative echo showed only mild aortic regurgitation, it was evident on aortoscopy that the conjoint cusp was retracted, thickened, and calcified, and the two cusps were not contacting each other centrally. Once the mini-Bentall procedure was completed, the 10 mm endoscope was inserted into an aortoscope connector (Delacroix-Chevalier, Paris), which provides a complete seal at the top end of the graft. The root graft was then pressurized by infusing crystalloid cardioplegic solution via the side port of the connector. This setup provides aortoscopic assessment (i.e., snorkeling) of the aortic valve and coronary button anastomoses from the inside of the graft. The author believes that this novel approach will further improve surgeons’ abilities to assess aortic valve function after aortic valve sparing root replacement.

The Crane Maneuver
To provide adequate exposure and surgical accessibility, it is important to anteriorize the aortic root, and bring the aortic annulus in the cephalad direction. This is achieved by placing three pledgeted 2-0 Ethibond horizontal mattress sutures above the commissures and hitching them up to the skin edges. This simple maneuver provides an excellent exposure of the aortic valve for the minimal access surgical approach. Even though the mini sternotomy terminates at the level of sinotubular junction, this maneuver could bring the aortic annulus forward in the cephalad direction by 2 to 3 cm. 

“French Cuff” Technique
Composite graft replacement of the ascending aorta and aortic valve was first introduced by Bentall and De Bono in 1968 (2). According to this technique, the aortic tissue surrounding the coronary ostia is directly sutured to the openings in the composite graft. These anastomoses were all made within the ascending aorta, and then the aortic wall was tightly wrapped over the conduit. This technique has been known as the wrap/inclusion technique (2). Coronary artery dehiscence and coronary false aneurysms may result from tension created by bleeding into the space between the graft and the wrap (3). A few technical modifications have been implemented, including the use of a reinforcement suture joining the cut edge of the aortic wall and the prosthetic sewing ring (4). 

In a mini-Bentall procedure, absolute hemostasis must be achieved. If there are any concerns regarding the hemostasis along the annulus due to suture spacing or severely calcified annulus, a second “haemostatic” layer is achieved by using a continuous 4-0 running polypropylene suture that incorporates the remnant of the aortic wall and the sewing cuff of the valve conduit. This technique works well for a mechanical valve conduit, as the sewing cuff is big enough to accommodate two rolls of anastomoses. 

However, when a bioprosthetic valve is used inside of a Valsalva graft, the second “haemostatic” layer is achieved using the “French Cuff” technique. First, the proximal cuff of the Valsalva graft is folded back over the outside of Valsalva portion of the graft to make the eponymous “French double cuff.” Second, the prosthetic valve is positioned inside the Valsalva graft (graft size = valve size + 5 mm). The annular sutures are passed through the sewing ring of the prosthesis first and then through the folded proximal edge of the Valsalva graft. Once all the sutures are passed through, the valve and the graft are parachuted down onto the annulus. The sutures are tied and cut sequentially around the sewing cuff. This step completes the first proximal layer anastomosis. Next, the second “haemostatic” layer is performed using a 4-0 running polypropylene suture, starting from the commissure between the left and right annuli and progressing clockwise circumferentially. It is important to ensure that this layer of running suture incorporates the remnant of aortic wall and the everted “French Cuff” edge.
 
Conclusion
In the strategy presented, the fundamental principles of a traditional aortic root replacement are respected, and it cannot be emphasized enough that a meticulous surgical technique to ensure absolute hemostasis is of utmost importance in minimally invasive surgery. This results in a complete aortic repair via a minimal access incision and successful treatment in selected patients with aortic root and/or ascending aortic aneurysms. 

References

1. Yan TD. Mini-Bentall Procedure: The “French Cuff” Technique. Ann Thorac Surg. 2016 Feb;101(2):780-2. doi: 10.1016/j.athoracsur.2015.06.092. PMID: 26777944. .
2. Bentall H, De Bono A. A technique for complete 12. replacement of the ascending aorta. Thorax 1968;23:338-9.
3. Nezic D, Cirkovic M, Knezevic A, et al. Modified Bentall procedure – ‘a collar technique’ to control bleeding from coronary ostia anastomoses. Interact Cardiovasc Thorac Surg 2008;7:709-11.
4. Copeland JG 3rd, Rosado LJ, Snyder SL. New technique for improving hemostasis in aortic root replacement

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