Bentall Procedure: Everything You Need to Know

A Surgery to Repair the Aortic Root and Aortic Valve

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The Bentall procedure is a type of serious open-heart surgery needed to repair the aortic root and the aortic valve, such as might be needed for an aortic aneurysm in this part of the aorta. The procedure is named for Hugh Bentall, who first performed and described it in 1968.

Heart surgeons during a heart operation

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What Is the Bentall Procedure?

The Bentall procedure is a type of open-heart surgery to replace the aortic valve and aortic root (and sometimes more of the ascending aorta). It might be formed as a pre-planned surgery or under emergency circumstances. To understand the Bentall procedure, it’s helpful to understand a little about the anatomy of the heart and blood vessels.

The aorta is the large blood vessel that carries oxygenated blood from the heart. Blood vessels leaving the aorta provide oxygenated blood to the whole body.

The aortic valve, which lies just where the aorta connects with the heart, prevents blood from flowing backward into the heart.

The aortic “root” is a term used for the very beginning of the aorta. You also might hear the term “ascending aorta,” which refers to a slightly longer portion of the aorta (before any blood vessels have branched off it), including the root itself.

Sometimes the aortic root can develop an aneurysm, the general term for a blood vessel that balloons out and becomes larger than normal in size. When that happens, it can affect how well the valve functions as well.

Contraindications

A person might not be able to have a Bentall procedure if they aren’t medically stable enough to have a major heart surgery (e.g., their blood pressure is too low).

Potential Risks

Like all forms of open-heart surgery, the Bentall procedure has inherent risks. It is a serious intervention, and unfortunately not everyone survives. One study cited the risk of death within 30 days of hospitalization at around 5%.

The risks of possible complications include the following:

  • Abnormal heart rhythm
  • Low cardiac output
  • Heart attack
  • Stroke
  • Infection (e.g., sepsis, pneumonia, or surgical wound infection)
  • Internal bleeding (which might necessitate surgical repair)
  • Sudden kidney failure (which might be temporary or permanent)
  • Prolonged need for mechanical ventilation
  • New aortic aneurysm or dissection of the aorta

You may have a greater risk of certain of these complications if you have other medical conditions (like diabetes) or if your existing heart condition is particularly severe. Fortunately, the risks of some of these complications have decreased since the procedure was first performed, due to improved surgical techniques.

Purpose of the Bentall Procedure

The problems with the aorta and aortic valve can happen due to a variety of medical problems.

One of the most common is Marfan syndrome, a genetic condition that causes problems with a person’s connective tissue, including some of the tissue in the aortic root and valve. This can cause the area not to form normally or to develop problems over time. In addition to other potential medical problems, a person with Marfan syndrome might have an aneurysm form in their ascending aorta.

However, sometimes people develop problems in these areas for other reasons. Other possible underlying causes include:

  • Other hereditary syndromes that affect the heart
  • Physical trauma
  • Infection (like from a bacterial infection)
  • Autoimmune disease (like from Takayasu arteritis)
  • Congenital heart problems
  • General degeneration (caused by high blood pressure, atherosclerosis, and smoking)

In any case, these problems need to be surgically repaired if the aneurysm is large enough. The most important consideration is the risk that the aneurysm will start to dissect. That means that the layers of the blood vessel will start to separate.

This can cause the artery to burst, leading to a life-threatening emergency. To prevent this, some intervention, such as the Bentall procedure, is necessary. The Bentall procedure might also be needed as an emergency surgery if an aneurysm has already ruptured.

Imaging

To evaluate whether a Bentall (or similar) procedure is needed, you’ll need some medical imaging. Depending on the context, this might mean one or more of the following:

  • Chest X-ray
  • Transthoracic echocardiography
  • Computerized tomography (CT) scan
  • Magnetic resonance imaging (MRI): Cardiac MRI and/or MRI angiography

Through these imaging techniques, your doctors can check out your specific anatomy and evaluate whether the Bentall procedure is the best way for you to go.

Choosing Surgical or Medical Management

Not everyone with an aortic root aneurysm will need surgical repair (such as a Bentall procedure). It’s important to weigh the risks of surgery with the risks of not having the surgery.

If the aneurysm is small, it’s unlikely to dissect. If that’s the case, your doctor might recommend waiting on surgery and monitoring you with imaging techniques, at least initially.

For people who don’t have an underlying medical condition that caused their problem (other than high blood pressure), it’s currently recommended to have preventative surgery when the aorta diameter is 5.5 centimeters (cm) or if it seems to be growing quickly.

However, your doctor might recommend the surgery even if your aorta isn’t quite that big if you have a condition like Marfan syndrome.

If you decide not to have surgery (at least for the present), your doctor may recommend treatment with medications instead, especially those to lower your blood pressure. For example, you might need to start taking a beta blocker (like propranolol) or an ACE-inhibitor (like captopril).

Other people may need to take a statin drug (like Lipitor) if they have atherosclerosis that may have contributed to their condition. However, none of these medications fixes the underlying problem.

Clearance for Surgery

Before your surgery is planned, your doctor will want to make sure you are in good condition for it. This will include a general medical history and medical exam. It may also include some tests like EKG, basic blood work like a complete blood count (CBC), and others as needed.

If you experience serious symptoms, like sudden chest pain or shortness of breath, call 911 right away. This may be a sign that your aneurysm has started to dissect. Seek immediate medical attention for this potentially life-threatening emergency.

How to Prepare

Picking Your Surgery Type

Depending on the exact situation, you might have surgical options other than a Bentall procedure. Sometimes, doctors may be able to repair the aortic root without needing to replace the aortic valve through a newer surgical technique. This is sometimes called a “valve sparing” procedure.

In this case, the procedure performed is not technically a Bentall procedure. This procedure may have a reduced risk of complications compared to a Bentall, such as the risk of endocarditis.

Another advantage over some types of Bentall procedures is that a valve sparing surgery does not require long-term treatment with anticoagulant medications. Some doctors now recommend such a procedure over a Bentall in situations in which it is medically possible. But it’s not always a viable option.

Bentall Procedure Valve Selection

When planning to have a Bentall procedure, one of the key choices to make is whether to have a mechanical valve replacement or a valve replacement performed with a synthetic, biologic material.

The advantage of choosing a mechanical valve is that they are very durable and last for many years. However, people who have mechanical valves need to be on life-long anticoagulation treatment (such as via warfarin).

This helps ensure that you don’t get a blood clot that forms on the replacement valve. However, these medications come with risks (particularly increased risk of bleeding) and a greater need for monitoring for the rest of your life.

On the other hand, if you have a synthetic biological valve replacement, you won’t need to take anticoagulation medications. A disadvantage is that these valves don’t last as long as mechanical valves, so you may be more likely to need a follow-up surgery.

Working with your physician, you can make the best surgical choice for you based on your clinical situation, your age, and your lifestyle preferences.

Location

The procedure will be performed in the surgical or cardiac wing of your chosen hospital.

What to Wear

It doesn’t matter what you wear when you come to the hospital. You may want to leave any valuables, such as rings, at home.

Before you go to surgery, you’ll need to change into a hospital gown. You’ll need to remove any jewelry, glasses or contacts, hearing aids, or dentures.

Food and Drink

Like other surgeries, you’ll need to not eat or drink ahead of time, in order to reduce the risk of complications. Typically, you’ll be asked not to eat or drink anything after midnight the night before your planned surgery.

Medications

Before the surgery, make sure your doctor knows about all the medications you are taking, including over-the-counter ones. Particularly make sure to ask about medications that might affect blood clotting, such as aspirin or anticoagulant medications like warfarin.

Your physician might want you to stop taking them for a time before the surgery, but don’t do this without checking in first. It’s also a good idea to bring a printed list of your medications on the day of your surgery itself.

What to Bring

Because you will need to be in the hospital for several days, bring whatever you need to help you feel comfortable (e.g., slippers, a robe). It’s also a good idea to bring your insurance information.

Pre-Op Lifestyle Changes

If you are a smoker, it’s a good idea to quit before your surgery. Even quitting the day before can help you reduce your risk of complications, but longer is better.

What to Expect on the Day of Surgery

Before the Procedure

You’ll be expected to arrive well ahead of your surgery. You’ll be evaluated by one or more health professionals who will make sure that you are in good health to move forward with the procedure.

For example, you’ll be asked about any new symptoms, like fever. You’ll also probably be asked again about other parts of your medical history, like your allergies and your current medications. If anything is unusual with your health, this is the chance to share that information.

Someone will also check your vital signs, like your blood pressure, and you’ll have a basic medical exam performed. Someone may also shave the area around your chest.

During the Surgery

The operation should take around five hours, but it might be more. (This doesn’t include the preparatory period or the time in surgical recovery). A whole surgical team will be available to monitor your vital signs and help get you through the surgery successfully.

Eventually you’ll be taken from a preoperative area into the surgical room itself. You’ll receive general anesthesia during the operation, so you won’t feel any pain, and you won’t remember anything about it afterward.

Someone will insert a catheter to collect your urine during the operation. You'll also have a special tube stuck down your airway, which will be connected to a ventilator.

When everything is ready, the surgeon will make a cut in your chest, through the breastbone, to access the aortic valve and the aorta.

During the part of the surgery on the heart and related structures, you will be connected to a heart-lung bypass machine. This machine can do the work that your heart and lungs would normally do. This allows the surgeon to stop your heart temporarily while working on the aorta and its valve.

The surgeon will clamp the aorta and remove the damaged section of the aorta and valve. Then the surgeon will replace that part of the aorta with a prosthetic tube (called a graft). Inside the graft is an artificial aortic valve (either of the mechanical type or one made of biological tissue).

The surgeon will surgically connect one end of the graft to your remaining, normal aorta. The other end containing the valve is also sewn into the heart. The surgeon will also need to sew the coronary arteries (that bring blood to the heart itself), to make sure they receive adequate blood flow after the operation.

After everything is in place, the clamp can be removed. You’ll come off the heart-lung machine and your heartbeat will be restarted, as the blood flows through the artificial valve and graft and out into the rest of your body.

Depending on the exact clinical situation, the Bentall procedure may not be the only procedure necessary for your heart. For example, you might need repair or replacement of a different heart valve, or you might need some other sort of heart intervention. If so, these can take place either right before or right after the Bentall procedure.

Your sternum may be closed with wires. The surgeon will also surgically close the incision across your chest. 

The exact details of the procedure will vary based on the specific version of the Bentall technique your surgeon is choosing. Don’t feel like you have to get overly involved in the details, but don’t hesitate to bring up any questions that you have.

After the Surgery

Someone will take you to a surgical recovery area, where you’ll be carefully monitored. After a while, you’ll wake up, but you may be groggy for a while.

At first, you may be attached to a ventilator via an endotracheal tube. You’ll have one or more tubes attached to drain excess fluid and air from your chest. You might also have a catheter in the artery in your wrist (an arterial line) so your medical team can better monitor your condition.

If everything seems to be going well, you’ll be moved to the room where you’ll stay overnight, probably in the intensive care unit. Here they can carefully monitor you and make sure you aren’t having any immediate complications from your surgery, such as blood clot in your leg or lungs.

If you need to, you can have medication for the pain following the surgery. Usually, people can eat and drink again the day following surgery. After a day or so in the intensive care unit, you will probably be able to move to a general medical floor.

You’ll need to stay in the hospital for several days until you are well enough to go home. During this time, people will regularly be checking on your incision to make sure it is healing properly.

They’ll also be checking to see that you are able to pass stool without straining (as extra pressure might put stress on your wound). The urine catheter and chest tube are able to be removed within a couple of days.

As soon as you can manage it, you’ll want to try moving around again. This will reduce your chance of complications, like forming a blood clot.

Recovery

Healing

Before you leave, you’ll receive instructions on follow-up care, such as continued care for your healing chest incision. You may still need to keep it away from water until your wound fully heals.

You’ll also receive instructions on when you will see your doctor again (such as a week or so later in an outpatient clinic). Someone will need to be able to drive you home. You won’t be able to do that yourself for a few weeks or so, or maybe more.

Call 911 right away for signs of potentially serious complications like sudden chest pain. Call your doctor promptly if you have other new symptoms, like fever. These might indicate a complication that needs medical attention.

Coping With Recovery

Even when you are ready to leave the hospital, you may still fatigue easily. You need to give yourself time to recover from this major surgery.

Some people will benefit from cardiac rehabilitation to help get them moving again. Your doctor is the best person to tell you when you are ready to return to your normal activities, but it may take you a several months to fully recover.

Long-Term Care

If you had a problem with your aorta and valve due to another condition, do what you can to decrease your risk of a future aneurysm. For example, if you have atherosclerosis and/or high blood pressure, taking your medications as prescribed may help you reduce your risk.

Quitting smoking may also help you decrease your risk of a future aneurysm and of certain complications.

Additionally, people who receive a mechanical valve as part of their Bentall procedure will need to receive life-long anticoagulation. As part of this, you may need to receive regular blood tests to make sure your blood is clotting the right amount.

Possible Future Surgeries

Some people who receive the Bentall procedure do very well and never need repeat surgery. However, some people eventually need to have another surgery.

This might be more likely to happen if you have a disease like Marfan syndrome, and the underlying problem causes another aneurysm to develop. In this case, you might need some kind of surgical repair on your aorta.

A Word From Verywell

There’s a lot to consider if you have a problem with your aorta and aortic valve that might benefit from the Bentall procedure. Surgery might or might not be the best option for you, depending on your situation.

Beyond that, you may have choices about your surgical options, including whether to have a Bentall procedure specifically and whether you want to receive a mechanical valve. Discuss all the pros and cons with your healthcare provider to help make the best choice for you.

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