Surgical repair of aortic root aneurysms in 280 patients

Bentall's technique for repair of annuloaortic ectasia has been associated with postoperative bleeding and with false aneurysms at the anastomotic site between the coronary orifices and valve-containing graft. To reduce the incidence of these complications, we modified the Bentall procedure, using a simplified technique to implant the graft and to create a fistula between the closed perigraft space and right atrium to control bleeding. A continuous suture of monofilament polypropylene was used to implant the prosthetic valve ring and to anastomose the coronary orifices to the Dacron fabric. In some instances, a brief period of hypothermic circulatory arrest was needed to perform the distal aortic anastomosis. Among 562 patients undergoing operation for aneurysm of the ascending aorta between January 1, 1980, and February 28,1990, 280 underwent graft replacement with a valve-containing composite conduit. Most (82%) had annuloaortic ectasia. In 267, we performed a classic Bentall procedure with direct anastomosis between the coronary orifices and fabric graft. The remaining 13 patients underwent other procedures for coronary connection. Early mortality was 5.0%. Reoperation for bleeding was needed in 13.2% of patients who underwent operation before we used the right atrial fistula technique and in 4.4% after we began to use the technique ( p = 0.044). Actuarial survival was 71% at 5 years and 65% at 7 years. For hospital survivors, it was 76% at 5 years and 70% at 7 years. During follow-up, only 9 patients have required reoperation. A false aneurysm at the coronary anastomosis, which was associated with prosthetic valve endocarditis, developed in 1 patient. No permanent fistulas have developed. Thus, by using simplified methods to implant the graft and to control postoperative bleeding, the Bentall technique can be performed successfully with excellent early and late results.