Adult

The Button Bentall Procedure

Nicholas T. Kouchoukos, MD, Marc Haynes, BSN, RN, and Joshua N. Baker, MD

Since the initial description of the composite valve-graft technique for repair of aneurysms
of the aortic root and ascending aorta with associated aortic valve disease by Bentall and
De Bono in 1968, modifications have been introduced to reduce the risks of major bleeding
and false aneurysm formation that were associated with this procedure. Currently, the
most widely used modification involves excision of the aortic valve, aortic root, and ascend-
ing aorta, suture of a composite graft into the aortic root and to the ascending aorta, mobili-
zation of the coronary arteries with a small rim of aortic tissue, and anastomosis of the
arteries to openings in the aortic graft. This has been termed the “Button Bentall” proce-
dure, and is presented herein.
Operative Techniques in Thoracic and Cardiovasculary Surgery 23:50 61 Ó 2019 Elsevier Inc.
All rights reserved.

KEYWORDS Aortic root replacement, Composite valve graft, Composite graft technique,
Bentall procedure

Introduction the grafts to the right atrial appendage using a polyester tube
graft. Although patency of the coronary grafts was demon-
I n 1968, Bentall and Debono in the United Kingdom
described a technique for complete replacement of the
ascending aorta and aortic valve using a composite graft con-
strated in some of the surviving patients, pseudoaneurysms
at the site of the distal aortic anastomosis and distal aortic
dissections were noted in some patients.
sisting of a prosthetic aortic graft sutured to a mechanical Because of difficulty encountered in directly attaching
valve.1 The aortic tissue surrounding the coronary arteries
the coronary arteries to the aortic graft in patients with
was sutured directly to openings in the aortic graft. Because
minimal displacement of the coronary arteries from the
the aortic grafts available at that time were not impervious to
aortic annulus or with large aneurysms and substantial dis-
blood, and because of concern about the risk of bleeding at
placement, and also in patients with aortic dissection
the anastomotic suture lines, the aneurysmal aortic wall was
involving the coronary arteries, infection, extensive calcifi-
wrapped securely around the graft in an effort to reduce this
cation of the aorta, and those undergoing reoperation,
risk. As experience with this technique accumulated, it was
other techniques were developed to preserve flow to the
noted that anastomotic leaks arising at the coronary artery coronary arteries. These included interposition of segments
and distal aortic suture lines resulted in false aneurysms that
of reversed saphenous vein between the aortic graft and
required reoperation.2 To reduce the frequency of this com-
the coronary ostia,4 suture occlusion of the coronary ostia
plication, Christian Cabrol et al in France introduced an
and placement of saphenous vein bypass grafts from the
alternative procedure that involved anastomosis of the ends
aortic graft to the 3 major coronary arteries,5 and use of
of an 8 mm polyester tube graft to the aortic tissue surround-
short interposition grafts of polytetrafluoroethylene
ing the right and left coronary arteries, and subsequent anas-
between the left coronary artery and the aortic graft.6 All
tomosis of the midsegment of this graft to an opening in the
of these techniques proved useful, and they continue to be
composite graft.3 The aneurysmal aortic wall was sutured used on a selective basis.
securely over the aortic and coronary artery grafts to reduce
An important advance in the management of ascending
blood loss. To prevent accumulation of thrombus in the peri-
aortic and concomitant aortic pathology involved mobili-
aortic space, a fistula was created from the space surrounding
zation of the proximal portions of the coronary arteries
by excision of a small cuff of surrounding aortic tissue,
and direct attachment of these buttons of aortic tissue to
Conflict of Interest Statement: The authors have nothing to disclose with
regard to commercial support.
openings in the composite graft. This technique, coupled
Source of Funding: Supported in part by a grant from the Missouri Baptist with the development of polyester aortic grafts that were
Health Care Foundation. impervious to blood, eliminated the need for wrapping of
Divsion of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical the aortic wall around the graft, and permitted an open
Center, BJC HealthCare, St. Louis, MO anastomosis of the aortic graft to the distal aorta (the so-
Address reprint requests to Nicholas T. Kouchoukos, MD, Missouri Baptist
Medical Center, 3023 North Ballas Road, Suite 150D, St. Louis, MO
called “open” or “button” technique). In a comparative
63131. E-mail: [email protected] study involving 153 patients, actuarial freedom from
50 1522-2942/$ see front matter © 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1053/j.optechstcvs.2018.12.002
Button Bentall 51

reoperation for any cause, including postoperative bleed- widely used technique for aortic root replacement (Fig-
ing among 105 patients who received the classic Bentall ures 1 9).
procedure was 67% at 8 years. For 48 patients in whom
the open technique was used, freedom from any reopera-
tion at 8 years was 92%, a significant difference Operative Technique
(P = 0.003).7 Nine patients in the Bentall (inclusion/wrap) If a bioprosthesis is used to replace the aortic valve, a
group developed pseudoaneurysms of the aortic or coro- composite graft is constructed using an aortic graft with a
nary arterial suture lines, whereas no patient in the open dilated sinus portion. The graft is 3 mm larger than the
technique group developed this complication. This and outer diameter of the valve prosthesis. The valve is posi-
subsequent studies have confirmed the safety and long- tioned inside the aortic graft and is sutured to the lower
term efficacy of the open or button modification of the rim of the graft which is not dilated, using a continuous
original Bentall procedure, and it is currently the most #4-0 polypropylene suture.
52 N.T. Kouchoukos et al.

Figure 1 A full median sternotomy incision is made, the pericardium is incised vertically, and retraction sutures are placed. Scanning of the
ascending aorta and proximal aortic arch with an ultrasonic probe is performed to identify disease-free areas suitable for cannulation and
clamping. The proximal aortic arch is cannulated through 2 purse-string sutures distal to the ascending aortic aneurysm adjacent to, or beneath
the innominate vein. Venous return to the pump-oxygenator is accomplished with a single 2-stage cannula inserted through a purse-string
suture in the right atrial appendage. Cardiopulmonary bypass is intiated and the perfusate is cooled to achieve a nasopharyngeal temperature
of 32°C-34°C. A venting catheter is positioned in the left ventricle through a purse-string suture in the right superior pulmonary vein. A bal-
loon-tipped catheter is positioned in the coronary sinus through a pledgeted purse-string suture in the right atrial wall. CPB = cardiopulmonary
bypass; RSPV = right superior pulmonary vein; SVC = superior vena cava.
Button Bentall 53

Figure 2 The aorta is occluded with the clamp positioned immediately adjacent to the aortic cannula. The aorta is transected, leaving a cuff of
tissue distally that is suitable for anastomosis to the aortic graft, and cold, (4°C) blood cardioplegia is infused through the coronary sinus can-
nula. The aorta is incised longitudinally to a level just above the aortic valve commisures and is transected at that level.
54 N.T. Kouchoukos et al.

Figure 3 (A) Pledgeted #4-0 polypropylene traction sutures are placed at each aortic valve commissure, and the valve leaflets are excised. (B)
The aortic tissue in the 3 aortic sinuses is excised (dashed lines), leaving a small rim. The coronary arteries are separated from the aortic sinus
tissue with small buttons of full-thickness aortic wall. Mobilization of the arteries is only enough to permit their attachment to the aortic graft
without tension.
Button Bentall 55

Figure 4 (A) Traction sutures are placed at the superior margin of the coronary buttons to avoid torsion and assure proper alignment when they
are attached to the aortic graft. Calibrated sizers are used to determine the appropriate size of the valve prosthesis. If a mechanical valve is used,
(as shown here), a composite prosthesis is selected that contains a woven, collagen-impregnated polyester graft which has a proximal sinus
portion that is larger in diameter than the distal tubular portion. The larger sinus portion reduces the distance, and thus the tension, between
the aortic graft and the ostia of the coronary arteries, and consequently the risk of bleeding at the coronary artery anastomotic sites. Pledgeted
mattress sutures of #2-0 braided polyester are placed circumferentially through the aortic annular tissue with the pledgets positioned on the
undersurface of the annulus and immediately adjacent to one another to secure a water-tight anastomosis. Suture placement begins in the right
coronary sinus, working clockwise, followed by the left sinus, working counter clockwise, and is completed in the noncoronary sinus, working
clockwise. The sutures are then passed through the sewing ring of the prosthesis. (B) The composite graft is positioned in the aortic annulus
and the sutures are tied snugly. If the aortic annulus is heavily calcified, or if there are other concerns about the integrity of the suture line, it is
reinforced with a circumferential, continuous #4-0 polypropylene suture which incorporates the remaining rim of aortic wall and the sewing
ring of the prosthesis.
56 N.T. Kouchoukos et al.

Figure 5 Anastomosis of the left coronary artery is performed next. An opening in the aortic graft is created directly opposite the artery and its
aortic button using a battery-operated cautery. The aortic tissue surrounding the coronary ostium is sutured to the graft with a continuous
# 5-0 or # 6-0 polypropylene suture, beginning posteriorly. If the aortic tissue is thin, friable, or dissected, a thin strip of PTFE felt can be incor-
porated into the suture line. PTFE = polytetrafluoroethylene.
Button Bentall 57

Figure 6 Anastomosis of the right coronary artery to the aortic graft is completed in a similar fashion.
58 N.T. Kouchoukos et al.

Figure 7 (A) If there is concern about the integrity of a coronary artery-to-graft anastomosis, with the potential for substantial bleeding from the
suture line, alternative techniques can be used. If the coronary arteries originate immediately adjacent to the aortic annulus and cannot be safely
attached to the aortic graft without tension, or if they are widely displaced superiorly or laterally by a large aortic root aneurysm, segments of
8 mm or 10 mm collagen-impregnated polyester grafts are interposed between the coronary artery and the aortic graft. A widely used configu-
ration involves positioning the tube graft to the left main coronary artery posterior to the aortic graft, suturing it to the aortic cuff surrounding
the ostium of the artery, and to an opening in the right lateral wall of the aortic graft using #5-0 polypropylene suture. For the right coronary
artery, a short segment of tube graft is interposed anteriorly between the ostium of the right coronary artery and the aortic graft. (B) The least
desirable but occasionally necessary alternative involves suture-closure of the left or right coronary ostium if it is severely stenotic or disrupted
by aortic dissection, and interposition of a segment of saphenous vein from the aortic graft to the more distal coronary artery using #6-0 poly-
propylene suture.
Button Bentall 59

Figure 8 Rewarming is commenced, the aortic graft is cut to the appropriate length and sutured to the ascending aorta using a #4-0 continuous
polypropylene suture. Prior to completing the suture line, volume is infused from the pump-oxygenator to evacuate air from the cardiac cham-
bers. After completion of the suture line, a needle vent is inserted into the aortic graft through a pledgeted purse-string suture to evacuate resid-
ual air, the left heart vent is removed, securing the purse-string suture, and cardiopulmonary bypass is discontinued. When all of the
intracardiac air has been removed from the heart as determined by transesophageal echocardiography, the aortic needle vent is removed and
the purse-string suture is secured.
60 N.T. Kouchoukos et al.

Figure 9 After protamine is administered, hemostasis is obtained and atrial and ventricular pacing wires are sutured in place. If there is excessive
bleeding from the distal aortic suture line, it can be wrapped with a cuff of residual aortic graft. Two drainage tubes are placed, one in the ante-
rior mediastinal space and one in the posterior pericardial cavity, and are brought out through separate incisions, The sternotomy incision is
then closed.
Button Bentall 61

Summary the procedures currently performed on the aortic root differ

The safety of the classic Bentall procedure and some of the substantially from the original aortic inclusion and side-
modifications of the procedure was established early after to-side coronary anastomotic technique. Thus the term “Ben-
the initial report by Bentall and DeBono.1 Operative mortal- tall” should be reserved for the procedure that was described
ity rates ranging between 4% and 10.6% were reported from in the original report.
several centers.2,8-10 All of these series included patients with
acute aortic dissection. Stamou et al reviewed the experience
with aortic root replacement from the Society of Thoracic References
Surgeons Adult Cardiac Surgery Database for patients oper- 1. Bentall H, DeBono A: A technique for complete replacement of the
ascending aorta. Thorax 23:338–339, 1968
ated upon between January 2004 and early 2010.11 Patients 2. Kouchoukos NT, Marshall WG Jr, Wedige-Stecher TA. Eleven-year
with acute aortic dissection and endocarditis were excluded experience with composite graft replacement of the ascending aorta and
from the analysis. Among 6018 patients who received either aortic valve. J Thorac Cardiovasc Surg 92:691–705, 1986
a mechanical or a stented bioprosthetic aortic valve graft, the 3. Cabrol C, Gandjbakhch I, Cham B: Aneurysms of the ascending aorta;
operative mortality was 4.2%. Risk factors for higher opera- total replacement with reimplantation of the coronary arteries. (author's
transl). Nouv Presse Med 7:363–365, 1978
tive mortality rates included presence of aortic stenosis, 4. Blanco G, Adam A, Carlo V: A controlled surgical approach to annulo-
increased age, and concomitant procedures. aortic ectasia. Ann Surg 183:174–178, 1976
A more recent study from the Society of Thoracic Sur- 5. Zubiate P, Kay JH: Surgical treatment of aneurysm of the ascending
geons database identified 8807 patients who underwent aorta with aortic insufficiency and marked displacement of the coronary
aortic root procedures between January 2011 and June ostia. J Thorac Cardiovasc Surg 71:415–421, 1976
6. Piehler JM, Pluth JR: Replacement of the ascending aorta and aortic
2016.12 Patients requiring urgent, emergent, salvage, or valve with a composite graft in patients with displaced coronary ostia.
reoperative procedures were excluded. Hospital mortality Ann Thorac Surg 33:406–409, 1982
was 2.2%. However, the analysis included 1650 patients 7. Kouchoukos NT, Wareing TH, Murphy SF, et al: Sixteen-year experi-
(19% of the total) who underwent a valve-sparing proce- ence with aortic root replacement. Results of 172 operations. Ann Surg
dure, and the patients undergoing aortic root replacement 214:308–318, 1991
8. Svensson LG, Crawford ES, Hess KR, et al: Composite graft replacement
were not analyzed separately. Complications of the entire of the proximal aorta: Comparison of techniques 348 patients. Ann
cohort included stroke (1.4%), renal failure (2%), reoper- Thorac Surg 54:427–439, 1992
ations for bleeding (3.6%), and assisted ventilation for 9. Aoyagi S, Kosuga K, Akashi H, et al: Aortic root replacement with a
>24 h (8.4%). composite graft: Results of 69 operations in 66 patients. Ann Thorac
The recent data indicate that elective replacement of the Surg 58:1469–1475, 1994
10. Midulla PS, Ergin A, Galla J, et al: Three faces of the Bentall procedure.
aortic root with a composite graft is a widely used procedure, J Card Surg 9:466–481, 1994
and that it can be performed with low early mortality and 11. Stamou Sc, Williams ML, Gunn TM, et al: Aortic root surgery in the
morbidity. Late follow-up studies involving large cohorts of United States: A report from the Society of Thoracic Surgeons database.
patients have demonstrated favorable long-term survival, J Thorac Cardiovasc Surg 149:116–122, 2015
particularly in younger patients.13,14 In a meta-analysis of 12. Vallabhajosyula P, Wellen T, Habertheurer A, et al: Outcomes of elective
aortic root replacement procedures in North America: Analysis of Soci-
7629 patients from 46 centers who underwent aortic root ety of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac
replacement and who were followed for a mean interval of Surg 2019 (in press).
6 years, the annualized occurrence rates of anticoagulant 13. DeMarco L, Pacini D, Pantaleo A, et al: Composite valve graft implanta-
related hemorrhage, thromboembolism, and endocarditis tion for the treatment of aortic valve and root disease: Results in 1045
were 0.64%, 0.77%, and 0.39%, respectively.15 patients. J Thorac Cardiovasc Surg 152:1041–1048, 2016
14. Dhurandhar V, Parikh R, Saxena A, et al: The aortic root replacement
The title assigned to this manuscript is “The Button Ben- procedure: 12-year experience from the Australian and New Zealand
tall.” However, it is important to note, as emphasized in a Sociery of Cardiac and Thoracic Surgeons Database. Heart Lung Circ
publication by Maddalo, Beller, and DeAnda entitled “A Ben- 25:11245–11251, 2016
tall is not a Bentall is not a Bentall: The evolution of aortic 15. Mookhoek A, Korteland NM, Arabkhani B, et al: Bentall procedure: A
root surgery,”16 that important modifications and refine- systematic review and meta-analysis. Ann Thorac Surg 101:1684–1689,
2016
ments to the original procedure described by Bentall and 16. Maddalo S, Beller J, DeAnda A: A Bentall is not a Bentall is not a Bentall:
DeBono have been made by a number of surgeons, and that The evolution of aortic root surgery. Aorta 2:169–178, 2014