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Long Term Outcome Following the Bentall Procedure -- Are Valve-Sparing Procedures In Adults Really Better?
Christian D Etz, Stefano Zoli, Robert M Brenner, Fabian Roeder, Carol A Bodian, Gabriele DiLuozzo, *Randall B Griepp
Mount Sinai School of Medicine, New York, NY
Background: Valve-sparing procedures have progressively been recommended for aortic valve and root/ascending aorta repair, especially in younger patients. The durability and long-term outcome of valve-sparing operations has, however, never been shown to be superior to the Bentall procedure.
Methods: We have followed a cohort of 142 consecutive, elective patients--all <65 years--who underwent a Bentall operation without concomitant procedures between 1989 and 2000. 85% were men; median age was 46 (13-64) years. Degenerative disease of the aorta was the most common indication for operation (86%, including 46% with bicuspid aortic valve); 8% had chronic dissection, and 6% atherosclerotic aneurysms. The ascending aorta was replaced in 94 patients (66%); 45 patients (32%) underwent hemiarch replacement, and in 3 (2%) the entire arch was replaced. A mechanical valve was used in the conduit in 88%, and a biologic valve in 12%.
Results: Follow up was 100% complete, with a median of 10.9 (6.4-19.5) years. Survival was >95% after five, 91% after ten and 88% after twelve years (figure); the linearized death rate was 1.2% per patient-year (table). There was no significant difference in overall survival after the Bentall procedure compared to a sex- and age-matched normal population (figure). Twenty patients (14%) experienced adverse events: all episodes of bleeding occurred in patients with a mechanical valve. One-third of all bleeding events occurred within the first postoperative year; thereafter, the bleeding rate declined to 1.1% per patient-year (during years 1-5) and thereafter to 0.5% per patient-year. Freedom from adverse events (table) was 87% after five, 86% after ten and 84% after twelve years. The probability of suffering a thrombembolic stroke declined after the first year (1.4% per patient-year) to <0.2% per patient-year thereafter. The reoperation rate was <0.1% per patient-year (table).
Conclusion: Long-term survival after the Bentall procedure appears superior to that of contemporaneously published valve sparing studies (David TE et al, JCTVS 2006: N=220 patients, mean age: 46±15 years, follow-up: 5.2±3.7 years; 5-year survival: 94%, 10-year survival: 88%). The stroke rate appears comparable (0.2% per patient year; table). Bleeding events affected chiefly patients with mechanical valves during the first postoperative year, and likely reflects a learning curve in anticoagulation management. An increased risk of endocarditis after the Bentall operation seems to be outweighed by a greater risk of myocardial infarction after valve sparing procedures. Aortic insufficiency--virtually negligible in patients after a Bentall procedure--occurs in about 15% of patients after valve-sparing even in experienced centers, and consequently the risk of requiring reoperation after valve-sparing surgery may be as much as 10-fold higher than after a Bentall procedure.In the adult population in whom anticoagulation is absolutely contraindicated the Bentall procedure may be as good if not better than valve-sparing procedures.  
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