“Wings of a Butterfly” Technique in Modified Bentall's Procedure

I have read with great interest the article by Lee at al describing a novel composite valve graft. By adding an additional upper sewing cuff sutured onto the Valsalva prosthesis tube immediately above the aortic prosthesis annulus (the added polytetrafluoroethylene graft), reinforcement suturing was performed between the upper sewing cuff and the residual native aortic sinuses of Valsalva wall in addition to annular suturing of the conventional prosthetic valve sewing cuff.[1] Then, coronary ostia were anastomosed end-to-side onto the tube graft of the Valsalva prosthesis. I agree with the authors on the fact that proximal anastomosis bleeding could represent an annoying complication following a modified Bentall's procedure. Several preventive techniques have been described to avoid such a complication and all of these techniques focus on the same principle: covering the proximal sewing plane. Distensions on the left coronary anastomosis in these procedures are a problem, as they are in a similar technique of Lee et al.[1] Lee et al use additional prosthesis to reinforce the annular suture line at the aortic valve annulus. Instead of this technique, it is easier to suture the native aortic wall directly with the tube graft of the conduit prosthesis.

It is a fact that the proximal bleeding during a Bentall's procedure is only detected after unclamping of the aorta and sometimes only after weaning from cardiopulmonary bypass (CPB). Any bleeding occurring at that time, especially if arising from the posterior aspect of the proximal sewing plane is hard to repair, especially when the anastomosis of the left main coronary artery to the Dacron graft renders mobilization of the graft hazardous. In all techniques, no new methods were described to reduce the bleeding from coronary ostial anastomoses. Therefore, we described a technique called “New Strict Graft Inclusion Technique for Replacement of the Aortic Root” to reduce or eliminate the bleeding from coronary ostial anastomosis.[2] In this technique, the aortic root is replaced with a composite valve graft. After transection of the aortic root at the level of the sinotubular junction, the aortic valve is implanted with a suitable composite valve graft. Two lateral openings in the Dacron tube, aligned with the coronary ostia, will allow them to be implanted directly into the graft ([Fig. 1]) as a side-to-end anastomosis. Once this is completed, the internal tubular Dacron graft is sutured together with the circumference of the external native aortic wall using at the level of the sinotubular junction ([Fig. 2]).

Fig. 1 Reimplantation of left coronary artery after implantation of aortic valve in Dacron tube of composite graft. Reproduced with permission from Cebi et al.[2]

Fig. 2 Suturing of native aorta with Dacron tube of composite graft and supporting pledgeted stitches in “dead” space, along with replacement of ascending aorta. Reproduced with permission from Cebi et al.[2]

Through the suturing of the native aortic wall with the tubular Dacron graft at the level of the sinotubular junction, as depicted in [Fig. 2], bleeding from the aortic root is no longer visible.[2] A “dead” space remains between the aortic annulus, coronary anastomosis, and sinuses of Valsalva. Any leakage through the ostial anastomosis as well as the annular suture line will drain into the dead space that exists between the Dacron prosthesis and the remaining sinuses of Valsalva. The following thrombosis in the dead space will stop further leakage. In our 28 cases, there was no requirement for surgical reexploration and no postoperative early mortality in this technique.[3] Gök and Başaran[4] supposed that the advantage of shorter CPB time and reduced intraoperative bleeding rates in our technique might improve short-term survival after high-risk aortic root procedures and may be used as a safe alternative approach for various aortic root diseases due to better hemostatic properties and lower in-hospital mortality rates.

Publication History

Article published online:
29 November 2022

• References

• 1 Lee SI, Choi CH, Park KY, Park CH. “Wings of a Butterfly” technique in modified Bentall's procedure. Thorac Cardiovasc Surg 2022; 70 (04) 339-340
• 2 Cebi N, Frömke J, Walterbusch G. Safe hemostasis by application of a new strict graft inclusion technique for replacement of the aortic root. Ann Thorac Surg 2003; 76 (02) 631-632
• 3 Cebi N, Frömke J, Özcelik K, Walterbusch G. Perioperative results of the aortic root replacement in strict graft inclusion technique. J Card Surg 2008; 23 (05) 505-510
• 4 Gök E, Başaran M. Long-term outcomes of modified Bentall procedure. Koşuyolu Heart J 2020; 23 (02) 111-116