Aortic root surgery. Bentall operation

Aortic root surgery ,Bentall opeartion and its modifications

1. (Bentall Operation) Rami Ibrahim Abdelrehim Assisstant lecturer of cardiothoracic surgery Al- Azher university b y Aortic Root Replacement surgery

2. Aortic root anatomy The aortic root connect the LV to the systemic circulation and its function is to provide intermittent unidirectional channeling of blood with laminar flow and minimal resistance .

3. Aortic root components - Aortic valve leaflets - Annulus - The sinuses of valsalva - The interleaflet triangles - The sinotubular junction (STJ)

4. - The normal range has to be corrected for age and sex - Aortic size index ( Zscore ) = aortic diameter by BSA

5. When to replace the aortic root ? - Annulo -Aortic Ectasia - Aneurysm of sinus of valsalva - Aortic Root abscess -Stanford type A thoracic aortic dissection - Small aortic root: if root sparing techniques are not possible

6. Aortic root assessment ?? Cradiac MRI Echocardiography (TTE,TEE) Multislice CT with contrast-

7. Aortic Root Replacement (Bentall operation) - Described by Hugh Bentall and Antony De Bono , london 1968 - include Replacement of the aortic valve, root and ascending aorta

8. The Classical Bentall procedure -opened the aortic aneurysm longitudinally, -sutured a mechanical caged-ball valve Starr–Edwards inside of the end of tube graft -sutured the mechanical valve incorporated inside the tube graft inside the aortic orifice with use of isolated sutures. - Coronary ostia anastomosed to holes in TG with inclusion technique. - distal anastomosis of graft to the ascending aorta - Wrapping the graft with the aneurysmatic sac

9. - The early results were tenuous anastomosis from implantation of coronaries into TG by inclusion Technique and furthure pseudoaneurysm formation at the coronary anastomosis - The contained blood between the graft and wrapping could tear-off the anastomosed coronary ostia cabrol ??

10. 1981, Christian Cabrol ) ) Cabrol shunt shunt by direct suturing of the right atrial appendage to the aneurysmatic sac or the connection was created with use of a vascular graft or greater saphenous vein ,however this shunt is temporary and thrombsed within few hours after protamine administartion and normalization of coagulation

11. Cabrol operation

12. Cabrol opeartion alternative technique of connecting the coronary ostia to the Dacron neoaorta by means of another Dacron graft 8 mm to both RT , LT ostia and the to the TG with oval 1.5 cm long side-to-side anastomosis. however, it also carried a risk of graft thrombosis or anastomotic stenoses . , the Cabrol technique used only in situations where the coronary ostia are so remote that they cannot be safely moved to the conduit . This is usually the case in reoperations where the coronary ostia are firmly encased in adhesions

13. Nicholas Kouchoukos , the button technique , 1980 Mobilization of coronary ostia free of tension ( modefied Bentall )

14. Modefication for better haemostasis Copeland technique ,1993 . French cuff” technique by Tristan Yan , 2016 To apply the “French Cuff” technique, the tube graft selected should be 5 mm greater in diameter than the valve size

15. Endo-button buttress technique by Pratali ??? modified Bentall : Kawazoe in 1993 and Kito in 1994 Carrel patch OR teflon felt to prevent the cutting through in case of poor quality of the coronary ostia aortic wall Hashimoto prefers patch from autologous pericardium

16. - Bentall procedure is performed through standered median sternotomy approach ,However it may be approached through limited upper ministernotomy (mini-Bentall) - Mechanical or bioprothetic valve (Bio- Bentall ) - Young , Redo,Anticoagulant

17. Bentall procedure is currently a routine operation. In-hospital mortality of this procedure has markedly decreased

18. DO NOT forget SCREENING of family member in pt with heriditary thoracic aortic aneurysm

19. Thank YOU