Heart Vessels (2016) 31:265–267
DOI 10.1007/s00380-014-0583-7
CASE REPORT
Surgery for detached coronary ostial anastomosis 21 years
post‑Bentall procedure
Shogo Isomura · Susumu Hosoda · Akira Shikawa 
Received: 31 March 2014 / Accepted: 12 September 2014 / Published online: 25 September 2014
© Springer Japan 2014
Abstract  Though a high frequency of postoperative
complications after an original Bentall procedure has been
reported, several procedures that reduce the incidence of
complications have been developed. Complications relating
to anastomoses of the interposed graft are infrequent but
life-threatening. This report describes a case of a 61-year-
old man who presented with heart failure secondary to
bilateral detachment of coronary ostial anastomoses and
graft stenosis 21 years after undergoing a modified Bentall
procedure. These complications were successfully repaired
by reconstructing the conduit and coronary arteries.
Keywords  Reoperation (aorta) · Surgery ·
Complications · CABG
Introduction
The original Bentall procedure was used to repair aneu-
rysms of the ascending aorta with aortic valve abnormali-
ties [1]. A high frequency of early and late postoperative
complications after this procedure, in the form of bleed-
ing at the aortocoronary suture lines and pseudoaneurysm
formation, has been reported. Now that several procedures
that reduce these complications have been developed,
life-threatening anastomotic complications of the inter-
posed graft are rarely seen [2–4]. We present a case of a
61-year-old man who presented with heart failure second-
ary to bilateral detachment of coronary ostial anastomoses
21 years after undergoing a modified Bentall procedure.
S. Isomura (*) · S. Hosoda · A. Shikawa 
Department of Cardiac Surgery, Sendai Cardiovascular Center,
21‑1 Honda‑cho, Izumi‑ku, Sendai, Miyagi 981‑3107, Japan
e-mail: ringo‑stars@infoseek.jp
Case report
A 61-year-old man presented with 3-month history of wors-
ening dyspnea and orthopnea was admitted to our hospital
for heart failure treatment. Twenty-one years previously, he
underwent a Bentall procedure with mitral valve replace-
ment for annuloaortic ectasia with aortic and mitral valves
regurgitation. A composite mechanical valve conduit,
Cooley graft (knitted Dacron; 24-mm) and St Jude Medical
(St. Paul, MN, USA) 23-mm aortic and SJM 29-mm mitral
valves had been implanted. Both coronary arteries had been
reconstructed using two short, separated 10-mm Cooley
grafts; one sewn to the left and the other to right coronary
artery ostium by an inclusion technique in which the proxi-
mal sides of both grafts were sutured to the lateral sides of
the conduit. The conduit had been wrapped within the aor-
tic wall. He made an uneventful postoperative recovery and
had been asymptomatic until 3 months before the present
admission.
Computerized tomography (CT) and aortography
showed pseudoaneurysm formation of the sinus of Vals-
alva, stenosis of the conduit (pressure gradient 30 mmHg)
and detachment of the interposed grafts, all of which had
reduced coronary artery perfusion (Fig. 1). Surgical treat-
ment was decided upon with the aim of reconstructing the
conduit and coronary arteries.
At surgery, after securing the left femoral artery, rest-
ernotomy was performed and cardiopulmonary bypass
established by cannulating the right femoral artery,
inserting a single two-staged cannula through the right
atrium, and right superior pulmonary vein venting. The
ascending aorta was cross-clamped beyond the distal
anastomotic site of the previous graft and cold crystal-
loid cardioplegic solution was antegradely administered.
After incising the pseudoaneurysm, bilateral dehiscences
13

266
Fig.  1  a, b Contrast CT images
showing detachment of the right
coronary artery from the inter-
posed artificial graft; whether
disconnection of the left
coronary artery has occurred is
unclear. c Lateral view showing
a compressed conduit (arrows)
Fig. 2  Left panel intraoperative photograph showing aortic aneurysm
after incision (left) and interposed graft dehiscence (right, arrow).
Middle panel schematic representation of the anastomotic dehis-
cences of the interposed grafts and supravalvular graft stenosis. Right
panel schematic representation after coronary reconstruction show-
of the interposed grafts were found at their proximal
anastomoses to the conduit. The distal anastomosis to
the right coronary artery ostium had become partially
disrupted, whereas the left coronary distal anastomosis
was intact (Fig. 2). A compressed main graft and small
amount of mural thrombus were also found in the lumen
of the pseudoaneurysm. The left 10-mm interposed graft
was re-anastomosed directly to the 24-mm main graft.
To reconstruct the right coronary artery, coronary artery
bypass grafting with a great saphenous vein was chosen;
mobilization of the right coronary artery was consid-
ered difficult because of its adhesion and fragility. The
right coronary artery was ligated at the proximal site and
the side hole of the 24-mm main graft closed directly
(Fig.  2). The aortic cross clamp time and bypass time
were 103 and 177 min, respectively.
The patient made an uneventful postoperative recovery
and was discharged from our hospital on the 33rd postop-
erative day. Contrast cardiac CT demonstrated improve-
ment in coronary perfusion and repair of the stenosis of the
ascending aorta.
13
Heart Vessels (2016) 31:265–267
ing the left 10-mm interposed graft has been reanastomosed directly
to the 24-mm main graft. Coronary artery bypass grafting was per-
formed to reconstruct the right coronary artery, and the right coronary
artery was ligated proximally
Discussion
The original Bentall wrap-inclusion method has been asso-
ciated with pseudoaneurysm formation at the coronary
anastomoses. These complications have been attributed to
tension developing at the aorto-coronary suture lines with
large aneurysms or to accumulation of blood inside the
aortic wrap. Various modifications for preventing these
complications have been proposed, including changing
the procedure from one- to two-lane coronary orifice anas-
tomosis, interposed graft techniques including the Piehler
and Cabrol methods, and the Carrel patch technique [2–4].
However, because procedures that use interposed grafts
for coronary reconstruction risk kinking and graft throm-
bosis, the Carrel patch technique with use of ostial aortic
buttons is currently the standard treatment for aortic root
reconstruction. Regarding the technique of the initial sur-
gery performed on this patient, Pablo et al. have reported
long-term results of 153 patients who underwent a modi-
fied Bentall procedure using two short grafts for coronary
reimplantation. The actuarial survival at 5 and 10 years
Heart Vessels (2016) 31:265–267 267
was 86.3 % ± 2.78 and 73.7 % ± 4.23, respectively. Only
one patient in their study required reoperation for coronary
anastomotic pseudoaneurysm [3]. As described above, the
incidence of pseudoaneurysm formation is less after a mod-
ified Bentall procedure than after the original procedure.
Asymptomatic detachment of the coronary artery is
often found during routine follow-up, but sometimes pre-
sents with chest pain or as sudden death. In our case, we
were unable to identify the exact timing of coronary artery
detachment. It is probable that the anastomotic dehiscences
of the interposed grafts and the aneurysm developed slowly
over weeks or months with concomitant gradual progres-
sion of ischemia and supravalvular aortic graft stenosis.
Thus, his symptoms gradually developed over at least
3 months, rather than suddenly. It is necessary to be aware
that heart failure without chest pain after Bentall procedure
is occasionally a symptom of pseudoaneurysm formation.
Possible causes of coronary anastomotic dehiscence
include fragility of the aortic wall (evident histologically),
procedures used to create coronary anastomoses, and dura-
bility of prostheses. Based on their finding that aneurysms
formed in 8.7 % of patients in whom an inclusion tech-
nique was used, whereas few aneurysms developed in those
in whom a non-inclusion technique was used, Kouchoukos
et al. [5] believe that inadequate coronary anastomoses are
attributable to the inclusion technique. This possibility is
consistent with our case, in whom the inclusion technique
had been used for coronary reconstruction and the right
coronary artery anastomosis did detach. However, the left
coronary artery anastomosis remained intact; conversely,
the anastomosis between the conduit and interposed graft
was disrupted. Because suture material had cut into several
segments during the 21 years since the original operation,
we postulated that suture material deterioration is another
factor that can contribute to detachment.
Nowadays, the button technique is preferred for recon-
structing the coronary arteries during aortic root surgery.
However, in cases of reoperation where there is severe
calcification of the aorta and difficulty in mobilizing the
coronary arteries, interposed graft techniques maintain a
significant role as bailout procedures. In our case, the tissue
surrounding the right coronary ostium was fragile and did
not seem strong enough to be sutured. We therefore decided
to reconstruct the right coronary with an aorto-coronary
bypass rather than using an interposed graft and to choose
a saphenous vein as a graft. It is true that the patency of
saphenous vein is lower than that of arterial grafts and its
patency is affected by several factors such as venous valves
and mechanical stress when it was harvested [6, 7]. But
saphenous vein is relatively easy to use owing to its plen-
tiful, length, and wall characteristics. Therefore saphenous
vein was preferred in the case of reoperation. Although
this procedure does not provide a complete reconstruction
(excision of the previous sac and coronary re-implantation),
it may still be useful as a limited bailout procedure. Indeed,
without a more complex and perhaps risker procedure the
possibility of further anastomotic complications at the old
left ostial suture line or even between the fatigued 10-mm
graft and the aortic conduit can not be excluded. In reop-
eration, it is important to base the choice of procedure on
information obtained during the operation.
In conclusion, 21 years after a modified Bentall proce-
dure, our patient presented with bilateral coronary ostial
anastomosis detachment, which had led to pseudoaneurysm
formation, conduit stenosis and heart failure. Although
the incidence of complications including coronary anas-
tomosis detachment and aneurysm formation has declined
as procedures have improved, similar cases could still be
encountered. Close follow-up is necessary after Bentall
procedures.
References
1. Bentall H, De Bono A (1968) A technique for complete replace-
ment of the ascending aorta. Thorax 23:338–339
2. Antonios K, Manish S, Sonia R, Julia G, Petros N, Declan O,
Thanos A (2011) Evolution and current applications of the Cabrol
procedure and its modifications. Ann Thorac Surg 91:1636–1641
3. Pablo M, Fabrice V, Cecile M, Malik L, Jean-Pierre C, Nguyen T,
Jean-Pierre V (2012) Modified Bentall procedure using two short
graft for coronary reimplantation: long-term results. Ann Thorac
Surg 93:443–449
4. Aldo DM, Stefano P, Gianclaudio M, Piero B, Giovanni B, Enrico
M, Uberto B (2003) Fate of coronary ostial anastomoses after the
modified Bentall procedure. Ann Thorac Surg 75:1797–1802
5. Kouchoukos NT, Marshall WG Jr, Wedigestecher TA (1986)
Eleven-year experience with composite graft replacement of
ascending aorta and aortic valve. J Thorac Cardiovasc Surg
92:691–705
6. Yorihiko K, Tomonori I, Tetsuya F, Motoyuki N, Yoshihiro M
(2014) A unique stenosis in saphenous vein graft visualized by
optical coherence tomography. Heart Vessels 29:278–281
7. Necla O, Nehir S, Ulku C, Banu CY, Barlas NA, Ozden V (2013)
Pressure applied during surgery alters the biomechanical proper-
ties of human saphenous vein graft. Heart Vessels 28:237–245
13
Copyright of Heart & Vessels is the property of Springer Science & Business Media B.V. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.