Historical Perspective

Aorta, October 2014, Volume 2, Issue 5: 169 178

DOI: http://dx.doi.org/10.12945/j.aorta.2014.14-021

Received: March 19, 2014

Accepted: July 16, 2014
Published online: October 2014

A Bentall Is Not a Bentall Is Not a Bentall: The

Evolution of Aortic Root Surgery
Scott Maddalo, BA*, Jared Beller, BSE, Abe DeAnda, MD, FACS
New York University Langone Medical Center, New York, New York, USA

Abstract

Introduction

Background: Aortic root pathology had been a known entity with a progressive and catastrophic course, long before
the methods to surgically address them were rst developed. Once reliable cardiopulmonary bypass was established, surgeons were able to pioneer new operative techniques, and in the half-century to follow, countless
modications and renements have provided todays surgeons with the surgical approaches that are currently at
their disposal. History: Denton Cooley and Michael De Bakey
reported the rst successful surgical intervention for aneurysms involving the ascending aorta in 1956. Nearly a decade later, Hugh Bentall described his modication, and
provided a name that would leave a lasting mark on aneurysmal surgery. In the decades to follow, numerous innovative surgeons improved on these original procedures to allow for a more reliable and consistent operation. Further,
Tirone David and Sir Magdi Yacoub each described their
methods to repair the aortic root while preserving the valve,
thus providing their patients with freedom from a prosthetic
or mechanical valve and improved quality of life. Conclusions: The development of surgical techniques required to
successfully care for patients with pathology of the aortic
root has evolved considerably since Cooley and De Bakeys
original report. Although it is common to hear aortic root
replacement referred to as a Bentall, the methods currently employed have gone through considerable evolution,
such that the techniques of today should not be referred to
as a Bentall.
Copyright 2014 Science International Corp.

Aortic root pathology is often discovered incidentally after imaging is performed in patients for unrelated reasons. The most common indications for surgery of the aortic root are dilatation or aneurysm that
disrupts the precise hemodynamic environment
unique to the root (producing aortic insufciency)
and/or increases the risk of rupture or dissection. In
the past, operating on the aortic root was reserved
only for catastrophic circumstances. Current surgical
repair of aneurysms affecting the aortic root and ascending aorta involves resection of the pathologic
section and insertion of a graft. Recent innovations
include aortic valve-sparing techniques, which provide patients with increased quality of life due to
freedom from anticoagulation therapy, and increased
longevity of the valve (compared to tissue valves). In
instances where there is also concurrent aortic insufciency or aortic cusp pathology, a composite valvegraft (either bioprosthetic or mechanical) may be
used if the valve cannot be repaired. The purpose of
this review is to focus on the historical aspects of
aortic root surgery and to illustrate the evolution in
operative technique.

Perspective and Evolving Indications

Key Words
Aortic root Bentall procedure Cabrol procedure
Valve-sparing surgery

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2014 Aorta.
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Aneurysms of the ascending aorta had been a well

known entity prior to the rst reports of their successful surgical management. There was little question as

*Corresponding author:
Scott Maddalo
NYU-Langone Medical Center
New York, New York 10016, USA
Tel: 1 212 263 7300, Fax: 1 212 263 3842, E-Mail: [email protected]

170

to the progressive and fatal course, particularly in

patients with Marfan syndrome or other connective
tissue disorders. Although the majority of patients
with isolated aneurysms remained asymptomatic, the
risk for catastrophic consequences was known to increase as the size of the aneurysm grew. Despite the
known natural history, little could be done to mitigate
the risks with medications or to offer a curative surgical option. The surgical techniques currently employed developed out of a stepwise progression that
began with the foundational challenges of overcoming cerebral anoxia and organ malperfusion, specically the development of the cardiopulmonary bypass
machine and the safe arrest of the heart. Over decades
these techniques evolved, with surgeons seeking to
recreate or maintain the intrinsic anatomical structure
and function of the aortic root, most recently with the
advent of valve-sparing procedures. Creativity, out of
necessity, drove the innovations of the 20th century
and enabled aortic root surgery to become reproducible, albeit potentially technically challenging, as the
procedure remains today.
Prior to the 1970s, aortic root surgery was predominately performed in the setting of acute aortic catastrophe, on largely unstable, critically ill patients. These
experiences with poor surgical candidates demonstrated an exceedingly high mortality. The innovative
proof of concept that Hugh Bentall described in 1968,
and the subsequent long-term track record that would
follow, encouraged programs to begin prophylactic
surgery, thereby reducing the risk of rupture and dissection, as well as offering a consistent, reproducible
surgical outcome that could provide hope to those
aficted with this pathology. Bentalls work would not
have been possible without the successes and failures
that preceded him, nor would aortic root surgery be
what it is today without the modications by those
that followed.

Functional Anatomy
The aortic root is the complex anatomical section
that lies between the outlet of the left ventricle and
the ascending aorta. Two virtual rings form the
boundaries of this space. Proximally, the basal ring is
dened by the aortic valve annulus. Distally, the sinotubular junction is marked by the superior limit of the
valve cusp attachments. In addition to these anatom-

Maddalo, S. et al.

Historical Perspective

ical landmarks, a critical component of valve physiology arises from the geometric relationships between
the sinotubular junction and the basal ring. This region forms the sinuses of Valsalva, which serve to
optimize cusp-loading, improve transvalvular hemodynamics, and minimize turbulence throughout the
cardiac cycle [1]. In recent years, a more precise understanding of the uid dynamics that arise from sinus
geometry has developed [2]. This knowledge has the
potential to guide prosthetic valve design and surgical
repair, with the goals of minimizing cusp fatigue and
stress, much like the native sinuses. Further, torsion
within the aortic root as a result of helical blood ow
functions to dissipate shear strains created during left
ventricular contraction. A nal anatomic consideration
is the asymmetry among the three aortic cusps. The
noncoronary cusp is the largest of the three and its
basal attachment is to brous tissue lying in close
proximity to the anterior leaet of the mitral valve. The
basal attachments of the left and right cusps are
muscular, and because of this, the anterior section of
the basal ring is more resistant to dilation.
Surgical Technique
Initial Reports through the 1960s
Denton Cooley and Michael De Bakey reported the
rst successful replacement of a fusiform ascending
aneurysm in 1956 [3]. Prior to their experience, the
means to correct aneurysms in this anatomical location had been limited to narrow-necked saccular aneurysms [4]. These could be corrected with tangential
excision and aortorrhaphy. Reliable cardiopulmonary
bypass had yet to be consistently performed, and
even a brief interruption of aortic ow proximal to the
aortic arch meant disastrous neurologic consequences. Cooley and De Bakeys report of the initial
introduction of cardiopulmonary bypass to aortic aneurysm surgery was an incredible leap forward that
allowed the surgeon to temporarily halt aortic ow
without the compromise in systemic perfusion that
would result in the absence of circulatory support.
With the aid of cardiopulmonary bypass, surgeons
now had the time and surgical exposure necessary to
excise the defect and suture in place a homograft
before restoring normal cardiac function.
In the years that followed, the surgical group at
University of Oregon Medical School was at work cre-

The Evolution of Aortic Root Surgery

Historical Perspective

ating and redesigning mechanical ball-valve aortic

prostheses [5]. They rst performed implantation of
their aortic ball-valve prosthesis in the fall of 1961.
Following that initial surgery, they worked through
several iterations of their prototype, in order to
achieve improved results. Their progression began
with a three-pronged cage made from a cobalt-based
alloy and a sewing margin consisting of a silicone ring
coated with a double layer of Teon cloth. Unfortunately, they observed an unacceptable rate of thromboembolic events in their early series. These sobering
results encouraged them to progressively reduce the
amount of exposed alloy, while modifying their material selection. By the end of the 1960s, they had altered
their model by shortening and completely covering
the cage with Dacron, while using a highly polished,
electron-beam welded ball [6].
Throughout the late 1950s and into the 1960s,
others replicated procedures similar to the one that
Cooley and De Bakey rst described [7,8]. With the
surgical experience of today, many of the attempted
modications may seem radical, but in the context of
their day, creativity was the only option. Initially, ideas
like bicuspidization of the valve through excision of
the noncoronary cusp seemed promising, as it created
a competent valve [911]. However, despite creative
attempts such as this, no lasting innovation was developed until 1964, when Myron Wheat reported his
teams efforts to replace the entire ascending aorta
[12]. Although the procedure performed may not have
involved the entire aorta as the title laid claim, its
legacy was secured as a description of how to handle
pathology extending proximal to the coronary ostia.
The patient they describe suffered from a syphilitic
aneurysm beginning at the aortic annulus and extending 11 cm to a point several centimeters before the
origin of the innominate artery [12], p.718. Their approach to the displaced coronary ostia was to resect
the aorta 1.5-2 cm proximal to this level, while leaving
a tongue of tissue surrounding the two coronary takeoffs. In this way, they maintained the integrity of the
ostia and ensured the sutures were far enough from
the coronary arteries to minimize the risk of thrombosis. Wheat modestly deected credit and claimed that
previously developed techniques had merely awaited
the appropriate patient [12], p.717. The next step in
root revision had occurred. Surgeons now had the
means to extend the excision beyond the level of the

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171

coronary ostia and avoided the need to reimplant the

coronaries.
In 1966, Cooley published what had been his
teams 10-year experience with aortic root and ascending aortic surgery [13]. At this early stage in the
development of root surgery, they highlighted the fact
that no single method of reconstruction was ideal, and
that the patients specic anatomy dictated which was
the most appropriate method. This prescient view still
holds true today, underscoring the importance of an
individualized approach with the multiple surgical
procedures now at our disposal. Further, at their point
in the technical development, they credited the nely
woven nonporous Dacron graft with minimizing the
hemorrhagic complications that arose as a result of
the routine heparinization needed for cardiopulmonary bypass.
While others continued to work tirelessly, recreating and extending aortic repair, the group at Oregon,
including Drs. Herr and Starr, were diligently at work
devising mechanical valves that would eventually be
used for Bentalls historic procedure [5,6]. In 1968, they
published their ongoing clinical experience and engineering progress [6]. Even at this early point in the
evolution of aortic root surgery, bold predictions
about future progress were envisioned by Starr. In
response to commentary on their article, he closed
with his belief that they were already approaching a
time when consideration of earlier surgery will be
possible [6], p.218. Although they were not yet ready
to encourage prophylactic surgery, they felt that if
their experience [were to] continue along the lines
that it has taken in the last few years, it may well be
possible to do so in the near future [6], p.219.
At the time of Bentall and De Bonos classic report,
a successful approach to proximal aortic pathology
using cardiopulmonary bypass had existed for over a
decade [14]. There is no doubt that their ingenuity to
use a composite valve-graft prosthesis was a major
step in the progression of aortic root surgery, and the
composite valve-graft, whether using a mechanical (as
originally done) or tissue valve, is still considered the
gold standard today. In addition to the introduction of
a composite valve-graft, the side-to-side anastomosis
of the coronaries to the aortic prosthesis added to the
legacy of the procedure. Although these two developments were crucial in the trajectory of the eld, the
authors fail to recognize some of the important steps
that led to the possibility of such a technical advance-

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Figure 1. Classic drawing of Bentalls original root replacement. Figure reprinted with permission from Bentall et al. [14].

ment. Notably, they credit Cooley with the development of a combination valve prosthesis and aortic
graft replacement, without mention of the work of
Wheat. Despite this, their innovation secured a lasting
name within aortic root repair. The early results of
subsequent procedures were complicated by the tenuous anastomosis resulting from implantation of the
coronaries into the graft with the inclusion technique.
Further, pseudoaneurysm formation at the coronary
anastomoses grew to be a well known concern following these original methods. The solution to the
limitation in proximal excision created a new challenge, one that would fuel the next era of innovation
seeking to improve on this technically challenging and
often unpredictable procedure.
Beyond a Classic Bentall: The Modications Necessary
for a Reliable Procedure
The specic anatomic-pathologic changes seen in
the aortic root are not consistent from patient to
patient. This is particularly evident when considering
the relationship of the coronary ostia to surrounding
structures. Commonly, the dilative and degenerative
process displaces the ostia to such an extent that
direct anastomosis to the graft is facilitated: such was
the case in Bentalls original procedure (Fig. 1). However, as the frequency of these operations grew from
isolated case reports to larger series, it became evident that there were individuals in whom the restricted mobility of the ostia precluded an uncomplicated anastomosis. In the subset of patients with
nondisplacement of the supra-annular segment, an
alternative means of anastomosis needed to be devised.

Maddalo, S. et al.

Historical Perspective

Interposition of a conduit that could serve as an

extension from the neoaorta to coronary artery was
needed, but the ideal choice of material and specic
method had yet to be established. In the mid 1970s,
reports began to arise in which such attempts were
made, but with inconsistent success. Blanco et al. [15]
reported a promising approach, rst unsuccessfully,
but later with a positive result. In the rst patient, both
Dacron and then later a saphenous vein graft were
used. Initially, Dacron was selected, but poorly visualized and inaccessible hemorrhage from the anastomosis site forced them to reinstitute bypass, take
down the graft, and make a second attempt to save
the patient using vein grafts. The second attempt
formed a hemostatic seal and allowed the patient to
be weaned off bypass. Unfortunately, the patient died
hours after the surgery due to uncontrollable arrhythmias, presumably from prolonged operative time. Despite the outcome of this initial attempt, they were
encouraged to recreate this approach and did so successfully in subsequent operations. They praised the
interposition of vein segments as it was felt to allow
for a more tension-free anastomosis, provide a means
for constant perfusion of the arterial tree during operation, and, most importantly, allowed the surgeon to
assess the suture lines for potential sites of bleeding
prior to removal of the cross clamp. They believed this
alteration held the key to consistent reproducibility,
essential for any lasting operative technique.
Though some surgeons believed a conduit would
be the answer to improving reliability, others felt this
added step should only be instituted as needed. In
1976, nearly a decade after Bentalls original description of his method, Zubiate and Kay [16] described
their experiences correcting aneurysmal dilation of
the ascending aorta. In 6 of the 41 patients they
operated on, either the friability of the tissue or undue
tension placed when creating the anastomosis forced
them to entertain use of a saphenous vein conduit.
Rather than direct end-to-end anastomosis from the
coronary ostia, as had been attempted before, they
elected a more distal section of the main coronary
trunks for the distal anastomosis. In this manner, they
sutured closed the coronary ostia, and then performed
an end-to-side anastomosis onto the corresponding
coronary artery.
Two years later, Cabrol described what would serve
as the foundation for a series of modications and
alterations [17]. Unique to his approach was a single, 8

The Evolution of Aortic Root Surgery

Historical Perspective

Drawing of Cabrols root replacement technique.

Figure reprinted with permission from Cabrol et al. [17].

Figure 2.

mm Dacron tube that functioned to supply the entire

coronary circulation. In his operative technique, Cabrol
rst began with an end-to-end anastomosis between
the left coronary orice and the conduit (Fig. 2). He
then shifted his attention to the completion of the
aortic revision and, following completion of this component, returned to the coronary system. The opposite end of the single Dacron conduit was anastomosed in an end-to-end fashion to the right coronary
ostia. Finally, the single coronary conduit was made
continuous with the aortic graft via a single side-toside anastomosis. Once the anastomoses were completed and adequate hemodynamics conrmed, the
aneurysmal wall was closed over the revision, and a
1.5 cm stula was created to the right atrial appendage. This was believed to be important in preventing
tense hematoma formation, while minimizing postoperative blood loss by returning it to the circulation.
Despite these creative solutions, Cabrols operations
were not without their unique complications, which
would only become apparent through further experience.
In the years to follow, modications to Cabrols
original procedure were described. In addition to Da-

Aorta, October 2014

173

cron and saphenous vein conduits, Piehler and Pluth

[18] made use of a beveled Gore-Tex interposition
graft. They stressed the importance of restricting the
length of this conduit, and recommended against using segments in excess of 15-20 mm. The particular
case presented in their report featured asymmetric
pathology of the coronary ostia, a presentation not
uncommon in their practice. While the left coronary
required a conduit due to insufcient displacement for
direct anastomosis, the mobility of the right coronary
permitted direct connection to the aortic graft via an
inclusion technique. As additional operative techniques were added to the surgeons armamentarium,
the hybrid approach they described further afrmed
the importance of decisions that suit a patients individual anatomy.
In 1986, Cabrol reported on the outcomes several
years following the operative technique he initially
described in 1978 [19]. At the time, this was one of the
rst large cohort studies with promising long-term
results, in some cases, up to eight years. Cabrol reported nding no pseudoaneurysms, a complication
that was often seen with the classic Bentall procedure
[20]. However, only 25% of patients were followed up
with angiographic studies. What became apparent
from later, larger, longer study periods were the complications owing to the distal aortic anastomosis. In
the radiologic literature at the time, false aneurysm
formation at this point was evident in up to 20% of
patients within a few years [19]. Further, in Cabrols
cohort of 100 patients, four suffered from late dissections originating from this very site.
There were clearly differences in opinion as to the
ideal modications to Bentalls procedure that would
make it an increasingly reproducible and safe procedure. This is highlighted by D. Craig Millers comments
that although Cabrols approach is ingenious, it may
be a solution in search of a problem [19], p.24. His
concern referred to adding unnecessary complexity to
a procedure that is not always required. In his practice,
patients who had nondisplaced coronaries with restricted mobility were ideally suited for a procedure
akin to the one described classically by Wheat. This
algorithm served as a means for Miller to avoid using
conduits and encountering the complications inherent to this addition.
A nal evolution that became increasingly prevalent during this era was best illustrated by Kouchoukos description of his modications throughout a

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174

series of 168 patients that he reported in 1991 [21].

Prior to 1981, an inclusion/wrap technique, in which
the intrinsic aorta enclosed the graft for hemostatic
purposes, was used. This was the generally accepted
standard, but the risk of tense hematoma formation
remained. As Cabrol demonstrated, a solution to this
was the introduction of an iatrogenic stula from the
periprosthetic space draining to the right atrium [17].
He was condent that this communication would
close spontaneously following the resolution of the
coagulopathy after surgery and, if not, it would prove
to be hemodynamically insignicant. In the years to
follow, a number of reports of late complications owing to this connection were published in the literature
[22,23]. Rather than drain the space, a method to
decrease the permeability of the graft would achieve
the same end. Kouchoukos began preclotting the Dacron graft with albumin, and this indeed improved
hemostasis. Kouchoukos was also instrumental in popularizing an alternative means of dealing with the
coronary anastomoses. By excising coronary buttons, the aortic-coronary anastomosis was facilitated,
and this approach became a standard operative technique. Without the need for aortic wrapping, an additional hurdle was overcome and the potential for
additional complications was avoided.
This era of innovation saw a dramatic decrease in
early complications and the development of an arsenal of techniques that allowed the surgeon to approach any particular anatomy with the condence
that it could be successfully repaired. Now, without
the same impediments faced by the early surgeons,
focus began to shift. The aim was to nd what would
be the ideal way to provide long-term benets of
operation, allowing surgery to be offered not only as
a life-saving operation, but also as a prophylactic
means to prevent disaster.
Into the Modern Era: The Trend to Incorporate
Valve-Sparing Techniques
The initial operative techniques developed in the
1960s and modied throughout the following decades are not all that dissimilar from those in practice
today. As results became more favorable, and larger
study cohorts were established, the surgical approach
was able to be rened based on data rather than
theory, securing reliable long-term results.
The ability to perform earlier surgery in patients,
where the pathologic process had yet to permanently

Maddalo, S. et al.

Historical Perspective

affect the leaets, was an attractive prospect. This

would enable restorative surgery without the inherent drawbacks of valve replacement. A native valve
best suits the complex dynamic anatomy of the
valve apparatus and enhances the maintenance of
left ventricular function and coronary ow under a
range of loading conditions. Not only is the possibility of a valve-conserving surgery ideal for hemodynamic factors, but it also eliminates the complications intrinsic to valve replacement surgery (e.g.,
anticoagulation and degeneration of bioprostheses). Despite the attractiveness of such a procedure,
the long-term results remained largely unknown
until the late 1990s.
Until large enough cohorts of patients had been
compiled and meta-analyses completed, there remained two competing methods of sparing the aortic
valve. The rst was developed by Sir Magdi Yacoub,
and had been used in his practice since 1979 [24,25].
The procedure, which he designed, later became referred to as a remodeling technique. The functional
focus was to preserve the native valve, while recreating the aortic sinuses believed to be important in
efcient ow of blood from the aortic root into the
coronary lumen and relief of stress on the native valve
leaets (Fig. 3). Yacoub achieved this goal by fashioning a scalloped Dacron graft such that three tongues
extended to replace the intrinsic sinuses. Interposed
between these three extensions, native tissue was left
intact at the attachment of the cusps. Once the graft
was attached, the coronary arteries would be mobilized and anastomosed to the neosynthetic aorta. During its development, this procedure seemed promising and, in fact, was adopted by many centers.
However, as more evidence accrued, it appeared that
this approach left patients susceptible to echocardiographically and clinically signicant aortic insufciency
[2628]. This can be attributed to the lack of stabilization of the aortic annulus. Without xing the diameter
of the aortic annulus, no protection from future dilation and alteration of root geometry is provided. This
is especially critical for patients with Marfan syndrome
and other connective tissue disorders. Additionally,
since aortic tissue was left behind in order to accommodate the suture line, this tissue could continue to
become aneurysmal as it was continually exposed to
aortic pressures.
In the late 1980s, Tirone David and his colleagues
at the University of Toronto developed an alternative

The Evolution of Aortic Root Surgery

Historical Perspective

Figure 3.

175

Valve-sparing procedure as done by Yacoub. Figure reprinted with permission from Yacoub et al. [25].

class of valve-sparing procedures [29]. Their procedure

went through numerous iterations and variations, but
classically the technique became referred to as reimplantation [30,31]. This approach had the benet of
stabilizing the aortic annulus by sewing the native
valve directly into a Dacron graft of a xed circumference (Fig. 4). This provided greater protection from
late complications than did Yacoubs remodeling, but
it did not recreate the geometry of the sinuses. The
signicance of this decit has yet to prove itself clinically, but theoretically, and experimentally, the lack of

Aorta, October 2014

sinuses places undue stress on the valvular apparatus.

An ideal approach would incorporate the annular stabilizing properties of reimplantation while mimicking
the native geometry of the sinuses of Valsalva.
Although Tirone David was instrumental in the
development of the reimplantation technique, it is not
to say that his group exclusively used this procedure.
In their 2006 paper that compared the results of the
two techniques, they stated that no particular criterion was used to select the type of aortic valve sparing procedure [32], p.348. Throughout the years they

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Historical Perspective
Table 1. David Classication by Miller for Valve-Sparing Aortic

Root Replacement Surgery

David

Type

Modication

I
II
III

Reimplantation
Remodeling
Remodeling

IV

Reimplantation

Reimplantation

Classic
Classic
Plus external synthetic strip over
brous portion of left ventricular
outow
Plus plication of graft (d 4 mm)
at sinotubular junction
Plus plication of graft (d 68
mm) at both sinotubular junction
and basal ring to create
pseudosinuses

d, diameter of aortic annulus.

Valve-sparing procedure as done by David. Figure

reprinted with permission from David et al. [35].

Figure 4.

rened their technique, adding numerous modications. A classication schema beyond simply calling a
procedure reimplantation versus remodeling was
needed, and despite the objections of David, Miller
popularized the David-I through David-V classication
(Table 1) [1]. He labeled Davids classic reimplantation
procedure using a cylindrical tube graft as David-I,
while Yacoubs classic remodeling procedure was
identied as a David-II. In this system, David-III referred
to a remodeling variation where a synthetic strip is
placed over the brous portion of the left ventricular
outow tract, achieving a narrowing and reinforcing
annulopasty. The nal two methods identied are
variations on reimplantation. David-IV refers to the
technique of using a graft 4 mm larger than the
annulus to allow for plication, and David-V employs an

Maddalo, S. et al.

even larger graft (6-8 mm larger than the diameter) in

order to facilitate the creation of pseudosinuses. Thus,
David-I, -IV, and -V are variations on reimplantation,
whereas David-II and -III are variations on the remodeling technique originally devised by Yacoub.
In the late 1990s through the present day, attention shifted to focus on the nest details in technique,
such as cusp reinforcement, graft sizing to allow for
billowing, and plication as a means to recreate sinuses.
Dr. Cameron and the group at Johns Hopkins have
published some of the largest series on elective repair
of patients with connective tissue disorders in need of
aortic root surgery [33]. Although a classic Bentall
(i.e., composite valve-graft replacement) remains the
gold standard in their practice, over the years they
have introduced valve-sparing procedures when possible. Their initial valve-sparing approach focused on
preservation of sinuses with a remodeling procedure,
but it soon became apparent that recurrent aortic
insufciency and annular dilation occurred in a significant number of patients soon after their initial procedure. At their center, as these results began to bear
out, they transitioned to the reimplantation technique. This transition coincided with the newly approved De Paulis Valsalva graft, and in May of 2002,
this combination became the exclusive procedure for
valve-sparing operations at Johns Hopkins [34]. Reimplantation with the Valsalva graft has demonstrated
promising results and provides both annulus stabilization and aortic sinuses, supplanting either of the
classic valve-sparing techniques.

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Historical Perspective

177

Conclusion
In the fty-eight years since De Bakey and Cooley
rst replaced an ascending aneurysm with the aid of
cardiopulmonary bypass, a number of surgeons devised innovative steps to improve patient outcomes.
From the creation of the rst useable aortic valve
replacement to the valve-sparing techniques described by David and subsequent modications, surgeons can now treat aortic root pathology without
removing a patients native aortic valve, which greatly
improves quality of life. The design of the De Paulis
Valsalva graft is another great addition to the surgeons arsenal and reinforces the need to continue
analyzing and improving surgical techniques based on
the dynamic physiologic environment of the aortic

root. While it is common to hear surgeons refer to

aortic root replacements as a Bentall, the procedures
currently employed have undergone an evolution,
enough so that what is done now does not resemble
the aortic inclusion and side-to-side coronary anastomosis technique. Bentall and DeBono rightfully deserve credit for popularizing the root replacement
approach, but others have contributed substantially as
well.
Conict of Interest
The authors have no conict of interest relevant to
this publication.

Comment on this Article or Ask a Question

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The Evolution of Aortic Root Surgery