Modified Bentall procedure: Mechanical vs biological valved conduits in patients older than 65 years☆
Introduction
The first successful simultaneous replacement of the entire ascending aorta and aortic valve was reported by Wheat et al. in 1964 [1]. Subsequently, Bentall and De Bono in 1968 described a more radical technique using a composite conduit [2]; the Bentall procedure and its subsequent modification by Kouchoukos et al. [3] has become for many years the procedure of choice for patients requiring combined replacement of the aortic valve and ascending aorta regardless of the underlying pathology. Recently, after the seminal paper by David and Feindel [4] the widespread diffusion of aortic valve-sparing operations in patients with annuloaortic ectasia has reduced the number of suitable candidates for a modified Bentall procedure (MBP). Nevertheless, due to increased life expectancy, a MBP may be still required in a fairly large number of elderly patients with aortic valve disease and ascending aorta pathology. In an aging population biological prostheses are preferred because of avoidance of long-term anticoagulation and a longer expected durability [[5], [6], [7]]; furthermore, for the same reason, even in younger patients, tissue valves with proven long-term durability may be also indicated, especially considering the potential future diffusion of valve-in-valve procedures [[8], [9], [10]].
In patients requiring a MBP, mechanical conduits have demonstrated excellent long-term results particularly in freedom from prosthesis-related events and stability of the procedure [[11], [12], [13], [14], [15]]; however, biological conduits are currently increasingly used being considered particularly suitable for elderly patients requiring a MBP [[16], [17], [18], [19]]. There are however few studies comparing the results of mechanical versus biological conduits and few data are available defining the ideal age limit to prefer one over the other. To specifically address this issue we have compared the long-term performance of mechanical versus biological conduits in patients ≥65 years of age undergoing a MBP.
Section snippets
Material and methods
We have retrospectively reviewed 282 patients ≥65 years of age undergoing a MBP (January 1994–May 2015) with a biological (Group 1, 173 patients) or a mechanical (Group 2, 109 patients) conduit at 4 Italian institutions. Institutional approval for the study was obtained (3416/2011, prot. 64168) and patient informed consent was waived due to its retrospective nature.
The main indication for surgery was aortic valve disease associated with ascending aorta or root dilatation; patients with acute or
Surgical data
Almost all operations were performed in each centre by the senior surgeon (AP, RS, UB, UL). In Group 1 the following conduits were used: hand-sewn composite conduits containing a Perimount Magna pericardial bioprosthesis (Edwards Lifesciences Corp., Irvine, CA) in 110 patients or a Mosaic porcine bioprosthesis (Medtronic Inc., Minneapolis, MN) in 18; pre-formed stentless porcine aortic roots in 23 (Medtronic Freestyle in 17 and Edwards Prima in 6) and BioValsalva conduits (Vascutek Terumo,
Discussion
In patients requiring simultaneous replacement of the aortic valve and ascending aorta the MBP still represents the treatment of choice. Although mechanical conduits have been associated with gratifying results even in the long-term [[11], [12], [13], [14], [15]], biological conduits are currently gaining widespread acceptance due to increasing age of patients referred for surgery [16,17,19,23,24]. The so called ‘bio Bentall’ is preferred in elderly patients, usually >75 years since in them
Conclusions
In conclusion, among patients ≥65 years of age, and particularly in those between 65 and 75 years, the MBP represents a valid surgical option, with satisfactory early and long-term results. Mechanical valved conduits are associated with a trend towards better late survival than biological valved conduits; however, patients receiving mechanical devices are more likely to experience thromboembolic and bleeding complications. In this specific subset a bio Bentall procedure may also appear
Declaration of Competing Interest
The authors have not conflict of interest to declare.
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The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.