The pertinent anatomy consists of the aortic valve and related pathology, sinuses of Valsalva, coronary ostia, ascending aorta, and aortic arch. Specific pathologic processes present different challenges in a Bentall procedure. The more common situations are bicuspid aortic valve stenosis (AS) or aortic regurgitation (AR) with a dilated ascending aorta, AR and ascending aortic aneurysm (e.g., Marfan syndrome), and acute or chronic aortic dissection.

The pertinent anatomy consists of the aortic valve and related pathology, sinuses of Valsalva, coronary ostia, ascending aorta, and aortic arch. Specific pathologic processes present different challenges in a Bentall procedure. The more common situations are bicuspid aortic valve stenosis (AS) or aortic regurgitation (AR) with a dilated ascending aorta, AR and ascending aortic aneurysm (e.g., Marfan syndrome), and acute or chronic aortic dissection.

The planning of the procedure requires preoperative echocardiography and cardiac catheterization with coronary angiography and optional aortic root angiography with panning into the aortic arch. A carotid artery Doppler examination may be useful. The use of a contrast magnetic resonance imaging (MRI) or computed tomography (CT) scan with three-dimensional reconstruction is standard to help measure the extent and size of the aneurysm.

The choice of valve should be determined in consultation with the patient. If there is no associated coronary disease, the procedure can be performed through a ministernotomy. In this case, peripheral venous cannulation is often necessary because of limited access to the right atrial appendage.

The need for circulatory arrest and possible electroencephalographic monitoring should be determined if the arch is involved or if the aneurysm extends distally to the level of the innominate artery, requiring circulatory arrest to perform an open anastomosis. When circulatory arrest is required, decisions about cerebral protection need to be made with regard to technique, cardiopulmonary bypass (CPB) setup, temperature, and antegrade perfusion.

A plan for cardioplegia administration is essential, especially if a ministernotomy is to be used. I prefer antegrade and retrograde del Nido blood cardioplegia readministered every 60 to 90 minutes.

Special consideration is given to the treatment of postprocedure coagulopathy. Administration platelets, coagulation factors, and possible factor VII may be necessary. I use heparin-coated CPB circuits. In addition, a Rotem device (Tem International, Basel, Switzerland) is used to guide component therapy for postoperative coagulation.

The Bentall procedure can be performed through a median sternotomy or ministernotomy, with a 4-cm vertical skin incision over the upper sternum and the midsternal split extending from the sternal notch to the right fourth interspace (J-shaped sternotomy).

Cannulation sites can be into the ascending aorta, transverse arch, femoral artery or, preferably, into a 6- or 8-mm Dacron graft anastomosed end to side to the right axillary artery. Axillary perfusion provides antegrade flow, facilitates antegrade cerebral perfusion if the innominate artery is clamped, and is especially useful in cases of aortic dissection.

The site chosen for cannulation depends on the anatomy, extent of pathology, and indications for the operation. For example, the axillary artery is preferred for all cases in which circulatory arrest is to be used. The upper ascending aorta or arch is a safe and convenient site in aneurysmal disease. If the replacement extends into the aortic arch, the arterial perfusion cannula will be removed during the circulatory arrest period, with subsequent direct cannulation of the graft or through a side limb.

Venous cannulation is through the right atrial appendage, with a triple-stage cannula or long femoral venous cannula, inserted by cutdown through a purse-string suture or percutaneously with a Seldinger technique. The position of the cannula in the right atrium is confirmed with transesophageal echocardiography (TEE).

To protect the heart, a cold blood cardioplegia solution or del Nido solution is infused antegrade directly into the aorta (if there is no aortic insufficiency [AI]), via the coronary ostia, and retrograde through the coronary sinus. A topical cold saline solution augments myocardial cooling. A del Nido solution provides excellent myocardial protection and should be readministered every 60 to 90 minutes. It also does not require a reperfusion strategy.

Systemic cooling to a temperature of 34°C (93.2°F) is sufficient for routine replacement of the aortic root, but a temperature of 12°–18°C (53.6°–64.4°F) is necessary if a total circulatory arrest technique is used. An isoelectric tracing on the electroencephalographic monitor can be a biologic guide to circulatory arrest. An antegrade cerebral perfusion (18°C; 64.4°F) technique can be used with moderate systemic hypothermia at 25°C (77°F).

An optional left ventricular (LV) vent inserted into the right superior pulmonary vein or pulmonary artery vent facilitates decompression of the LV. With severe AI, the heart will distend in spite of venting the left ventricle, especially during fibrillation induced during the cooling period.

Cardiac distention during cooling will require cross-clamping the aorta and the initiation of cardioplegic arrest. As cooling continues, the proximal portion of the procedure can be performed—valve replacement and coronary button reimplantation. As soon as the goal systemic temperature is achieved in circulatory arrest cases, the proximal portion of the procedure is stopped and the arch replacement performed. Antegrade cerebral perfusion can extend the safe circulatory arrest time. Retrograde superior vena cava (SVC) perfusion is most effective in preventing the embolization of debris and air in very atherosclerotic aneurysms. In addition, monitoring bilateral near-infrared oxygen saturation over the forehead helps guide the possible need (e.g., a reduction in left-sided oxygen saturation) for direct perfusion of the left carotid in addition to the right carotid perfusion by clamping the innominate artery.

After the arch replacement is completed, the graft can be cannulated. If the axillary artery has been used, antegrade perfusion and de-airing of the arch are initiated. The graft is clamped, and rewarming is begun. The proximal portion of the procedure is completed. Finally, the graft to graft anastomosis is completed.