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Year : 2023  |  Volume : 11  |  Issue : 1  |  Page : 34-39

Bentall through a right mini-thoracotomy: A single-center experience

Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India

Date of Submission16-Feb-2023
Date of Decision23-Feb-2023
Date of Acceptance01-Mar-2023
Date of Web Publication12-Apr-2023

Correspondence Address:
Manish Jawarkar
Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_6_23

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Objective: The minimally invasive right thoracotomy approach is being increasingly used for aortic valve surgeries. It has several benefits in terms of decreased blood loss and length of hospital stay as compared to conventional sternotomy technique. Selected patients requiring aortic root and ascending aorta surgery can be operated on using a similar approach. In this case series, we share the outcomes of Bentall surgery done through right mini-thoracotomy.
Methods: This was a single-center retrospective study of five patients who underwent elective right mini-thoracotomy modified Bentall Procedure. Instruments routinely used in minimally invasive cardiac surgery were used. The outcomes that were evaluated include cross-clamp times, cardiopulmonary bypass (CPB) times, time to extubation, total length of intensive care unit (ICU) and hospital stay, re-exploration rates, and inhospital and 30-day mortality.
Results: The mean CPB times and cross-clamp times were 128 and 96 min, respectively. The total circulatory arrest was used in two patients with a mean time of 12 min. The mean time to extubation was 7 h. The mean ICU stay and the total length of hospital stay were 1.5 and 5 days, respectively. No patient required re-exploration for bleeding. We did not have any inhospital or 30-day mortality.
Conclusion: The right mini-thoracotomy modified Bentall procedure is reproducible and safe in selected patients with annuloaortic ectasia.

Keywords: Bentall procedure, minimally invasive cardiac surgery, right mini-thoracotomy

How to cite this article:
Manek P, Shah M, Madkaiker A, Jawarkar M, Wadhawa V, Doshi C. Bentall through a right mini-thoracotomy: A single-center experience. Heart India 2023;11:34-9

How to cite this URL:
Manek P, Shah M, Madkaiker A, Jawarkar M, Wadhawa V, Doshi C. Bentall through a right mini-thoracotomy: A single-center experience. Heart India [serial online] 2023 [cited 2023 May 28];11:34-9. Available from: https://www.heartindia.net/text.asp?2023/11/1/34/374104

  Introduction Top

Bentall and De Bono first described their technique for complete replacement of the ascending aorta in 1968.[1],[2],[3] This was done through a median sternotomy. Even today, this is the most favored approach for Bentall procedure. However, minimally invasive approaches for the aortic root and ascending aorta are being increasingly performed.[2],[3],[4],[5],[6],[7],[8] Minimally invasive approach has several benefits in terms of bleeding, decreased hospital stay, and risk of infections as compared to median sternotomy.[6],[9] Aortic valve replacement (AVR) is being increasingly performed using right mini-thoracotomy approach with proven benefits in terms of blood loss and length of hospital stay.[10],[11] Thus, increasing attempts are being made to extrapolate these benefits in more complex aortic surgeries. However, there is a dearth of evidence for the use of mini-thoracotomy for Bentall surgery. LaPietra et al.[12] published their case series of 20 patients undergoing mini-thoracotomy AVR with concomitant replacement of the ascending aorta with improved outcomes. Furthermore, the technique of right mini-thoracotomy AVR with ascending aortic and proximal arch aneurysm has been recently illustrated by Lamelas and LaPietra.[13] They performed six aortic root replacements using a stentless porcine miniroot with coronary anastomosis, thus showing that Bentall procedure can be done using right mini-thoracotomy incision. In the recent case series by Johnson et al.,[14] right mini-thoracotomy Bentall was done in seven patients with shorter recovery time and reduced blood loss. The aim of this series is to put forward our initial clinical results of the right mini-thoracotomy Bentall procedure.

  Methods Top

Approval for the study was obtained from the institutional ethics committee. Being a retrospective study, the informed consent was waived off by the ethics committee. We reviewed five patients who underwent right mini-thoracotomy Bentall at a single center from January 2015 to January 2018. All these patients were operated on by a single primary surgeon and assistants. Outcomes were evaluated in terms of cardiopulmonary bypass (CPB) and cross-clamp times, total circulatory arrest (TCA) time, time to extubation, intensive care unit (ICU) and hospital stay, re-exploration for bleeding, and incidence of postoperative complications including infections, Cerebrovascular stroke, and renal failure.

Data availability statement

The datasets generated during and/or analyzed during the current study are not publicly available to maintain confidentially but are available from the corresponding author on reasonable request.

Surgical technique

The patient is placed in supine position with the left lateral tilt of 30°, after applying external defibrillator pads. A 5-cm skin incision [Figure 1] is placed horizontally along the right second intercostal space. The right pleura is entered and the chest retractor is placed. The pericardium over the aorta is opened vertically toward the mid of the right atrium below and the arch of the aorta above. Open femoro-femoral cannulation is done and CPB is established through a transverse skin incision along the inguinal crease [Figure 2]. The patient is cooled to 32°C (24° in case of TCA for distal open anastomosis), and a left ventricular (LV) vent is placed through the right superior pulmonary vein. A signet ring clamp is used for aortic cross-clamping and is introduced through the main incision. In two cases, we used a conventional straight aortic cross-clamp introduced through the thoracotomy incision. The aorta is clamped and opened, and direct ostial cardioplegia (St. Thomas modified cold blood cardioplegia) is given.
Figure 1: Skin incision

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Figure 2: Femoral cannulation

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The aneurysmal aorta is excised and coronary buttons are harvested [Figure 3] and [Figure 4]. Next, the aortic valve leaflets are excised and the annulus is decalcified. Annular suturing is done using polyester 2-0 pledgeted sutures with pledget on the aortic side. Appropriate-size valved aortic conduit (St. Jude© Valved Conduit) is placed [Figure 5]. Once the conduit is secured to the annulus, the left coronary button is reimplanted in the appropriate position [Figure 6]. Following this, the distal anastomosis is performed [Figure 7]. TCA with open distal anastomosis is done whenever necessary. After the conduit is secured in position, the right coronary button is reimplanted [Figure 8]. All the anastomoses are secured with surgical glue. A knot pusher is used in selected cases. De-airing is done and the cross-clamp is removed. The patient is gradually rewarmed and with the return of cardiac rhythm, weaned of from the bypass. Femoral vessels are repaired, a single chest drain is placed through an aortic cross-clamp incision, and chest closure is done in layers. The patient is then shifted to the postoperative ICU [Figure 9].
Figure 3: Left coronary button

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Figure 4: Right coronary button

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Figure 5: Suturing the composite valve graft

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Figure 6: Reimplanting the LMCA. LMCA: Left main coronary artery

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Figure 7: Distal anastomosis

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Figure 8: Reimplanting the RCA. RCA: Right coronary artery

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Figure 9: Final completion of the procedure

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All the patients were followed up in the outpatient department. The duration of follow-up was 24 months. The first follow-up visit was at the 1st month postoperatively, followed by 3 months and thereafter every 6 months. Transthoracic echocardiography was done at 1 month, 6 months, 1 year, and 2 years. Postoperative echo gradients, ejection fractions, severity of mitral regurgitation if any, and LV remodeling were noted.

  Results Top

The mean age of our patients was 40 years; there were four males and one female. Three patients had severe aortic stenosis and two had severe aortic regurgitation. The mean ejection fraction was 53% with an average aneurysm size of 5.0 cm. Two patients were hypertensive and one had diabetes mellitus [Table 1]. Three patients were in NYHA III and two were in NYHA II. All the patients had St. Jude© valved aortic conduit implanted of size 23 mm in three patients and 25 mm in two patients. The operative outcomes are denoted in [Table 2]. The mean CPB times were 128 min and the mean cross-clamp times were 96 min. TCA was used in two patients with a mean TCA time of 12 min. The postoperative results are shown in [Table 3]. The mean time to extubation was 7 h, the mean ICU stay was 32 h, and the mean hospital stay was 4 days. None of the patients required postoperative blood transfusion or re-exploration for bleeding. There was no incidence of wound infection. One patient had postoperative renal dysfunction which recovered spontaneously. None of the patients had postoperative stroke or sepsis. We did not have any inhospital or 30-day mortality.
Table 1: Demographic parameters

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Table 2: Intraoperative and postoperative parameters

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Table 3: Follow-up parameters

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Before discharge, two-dimensional echo was done in all the patients and routinely on follow-up. Mean ejection fraction (upon hospital discharge: 54 ± 18; at the end of the follow-up: 56 ± 13; vs. preoperatively: 53.3 ± 11.22), a difference which was not statistically significant. The mean gradient across the prosthetic valve was 11.26 ± 1.2 mmHg, and none of the patients had a postoperative pericardial collection. Clinically, four patients were in NYHA I at 2-year follow-up and one patient was in NYHA II [Table 3]. None of them complained of pain at the incision site and were satisfied with the cosmesis [Figure 5].

  Discussion Top

AVR is being routinely performed by right mini-thoracotomy approach with better results in terms of lower incidence of wound infection, lower ICU and total hospital stay, and decreased need for blood transfusions. This success for mini-thoracotomy AVR can be utilized for complex aortic root and ascending aorta surgeries as suggested by LaPietra et al.[12] We also report the safety and efficacy of right mini-thoracotomy approach for Bentall procedure in a select subgroup of patients.

Our case series has shown that the length of ICU stay and hospital stay is significantly lower in right mini-thoracotomy as compared to sternotomy [Table 4].
Table 4: Comparison of techniques

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In our series, we did not have any inhospital or 30-day mortality. We had a mean ICU stay of 32 h and a mean hospital stay of 4 days which are comparable to that reported by LaPietra et al.[12] The mean time to extubation and mean CPB time and aortic cross-clamp times were significantly less than that reported by LaPietra et al.[12] and Johnson et al.[14]

In our series, we included patients with aortic valve stenosis or regurgitation with aortic aneurysm limited to the aortic root, ascending aorta, and proximal arch of the aorta. With respect to aortic valve pathology, we avoided this approach in patients with severe aortic annular calcification. Aortic valve calcification was not a contraindication. In addition, patients with associated coronary artery disease requiring coronary artery bypass grafting or any other concomitant procedures and patients with significant aortic arch involvement or peripheral arterial disease were excluded from the study. Hence, computed tomography aortogram with B/L lower-limb angiography was routinely done in all the patients. We avoided using this approach in emergency cases and morbidly obese patients. Distal anastomosis was usually done in a closed fashion in most of the patients. In two patients with involvement of the distal ascending aorta, we did hemiarch replacement, for which we went on TCA with open distal anastomosis. In these two cases, we had to use a straight ascending aortic clamp. A knot pusher was used in one case to secure the left coronary button anastomosis due to increased depth. Surgical glue was used in all the patients following the completion of all the suture lines. De-airing was done routinely under transesophageal echocardiogram guidance in all the cases. Although none of our patients required re-exploration for bleeding, for mini-AVR cases done in our institute, we use the same incision for re-exploration. This means that in mini-Bentall cases same right mini-thoracotomy approach can be used for re-exploration.

Follow-up of these patients has shown that this approach is as safe as open technique in terms of CPB times and cross-clamp times. The mean aortic cross-clamp time and CPB time in our open sternotomy patients are less. The need for blood transfusion and postoperative chest drain output was also similar to those who underwent open surgery. This approach had clear benefits in terms of ICU and total hospital stay. Our experience has shown that minimally invasive approach to Bentall procedure is associated with shorter recovery time; however, further studies are required to prove this conclusively.

Study limitation

The main drawback of this study is that it is a retrospective study involving only five patients. Further studies with a larger subgroup of patients are needed. Furthermore, all the patients had normal or near-normal ejection fractions without any significant comorbidities. Hence, generalization to sicker patients is not possible.

  Conclusion Top

Bentall procedure can be performed in a safe and reproducible through right mini-thoracotomy in selected patients. However, further studies with more number of patients are needed to conclusively comment on clinical outcomes in comparison to open Bentall procedure.

Financial support and sponsorship

This study was financially supported by the U.N. Mehta Institute of Cardiology and Research Center.

Conflicts of interest

There are no conflicts of interest.

Ethical approval

For this study Institutional Ethics Committee approval has been taken.

Authors' contributions

Pratik Manek: Concepts, Design, Literature search, Clinical studies, Data acquisition, Data analysis; Mausham Shah: Concepts,Design, Literature search, Clinical studies, Data acquisition, Data analysis; Ashish Madkaiker: Concepts,Design,Literature search, Clinical studies, Data acquisition, Data analysis; Manish Jawarkar: Concepts, Design, Literature search, Clinical studies, Data acquisition, Data analysis; Vivek Wadhawa:Manuscript review; Chirag Doshi : Manuscript review.

  References Top

Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-9.  Back to cited text no. 1
Yan TD. Mini-Bentall procedure. Ann Cardiothorac Surg 2015;4:182-90.  Back to cited text no. 2
Lentini S, Specchia L, Nicolardi S, Mangia F, Rasovic O, Di Eusanio G, et al. Surgery of the ascending aorta with or without combined procedures through an upper ministernotomy: Outcomes of a series of more than 100 patients. Ann Thorac Cardiovasc Surg 2016;22:44-8.  Back to cited text no. 3
Mok SC, Ma WG, Mansour A, Charilaou P, Chou AS, Peterss S, et al. Twenty-five year outcomes following composite graft aortic root replacement. J Card Surg 2017;32:99-109.  Back to cited text no. 4
Perrotta S, Lentini S. Ministernotomy approach for surgery of the aortic root and ascending aorta. Interact Cardiovasc Thorac Surg 2009;9:849-58.  Back to cited text no. 5
Tabata M, Khalpey Z, Aranki SF, Couper GS, Cohn LH, Shekar PS. Minimal access surgery of ascending and proximal arch of the aorta: A 9-year experience. Ann Thorac Surg 2007;84:67-72.  Back to cited text no. 6
Perrotta S, Lentini S, Rinaldi M, D'armini AM, Tancredi F, Raffa G, et al. Treatment of ascending aorta disease with Bentall-De Bono operation using a mini-invasive approach. J Cardiovasc Med (Hagerstown) 2008;9:1016-22.  Back to cited text no. 7
Abjigitova D, Panagopoulos G, Orlov O, Shah V, Plestis KA. current trends in aortic root surgery: The mini-Bentall approach. Innovations (Phila) 2018;13:91-6.  Back to cited text no. 8
Mikus E, Micari A, Calvi S, Salomone M, Panzavolta M, Paris M, et al. Mini-Bentall: An interesting approach for selected patients. Innovations (Phila) 2017;12:41-5.  Back to cited text no. 9
Malaisrie SC, Barnhart GR, Farivar RS, Mehall J, Hummel B, Rodriguez E, et al. Current era minimally invasive aortic valve replacement: Techniques and practice. J Thorac Cardiovasc Surg 2014;147:6-14.  Back to cited text no. 10
Bowdish ME, Hui DS, Cleveland JD, Mack WJ, Sinha R, Ranjan R, et al. Aç comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: A propensity score analysis of 492 patients. Eur J Cardiothorac Surg 2016;49:456-63.  Back to cited text no. 11
LaPietra A, Santana O, Pineda AM, Mihos CG, Lamelas J. Outcomes of aortic valve and concomitant ascending aorta replacement performed via a minimally invasive right thoracotomy approach. Innovations (Phila) 2014;9:339-42.  Back to cited text no. 12
Lamelas J, LaPietra A. Right minithoracotomy approach for replacement of the ascending aorta, hemiarch, and aortic valve. Innovations (Phila) 2016;11:301-4.  Back to cited text no. 13
Johnson CA Jr., Siordia JA, Wood KL, Robinson DA, Knight PA. Right Mini-thoracotomy bentall procedure. Innovations (Phila) 2018;13:328-31.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

  [Table 1], [Table 2], [Table 3], [Table 4]


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