Bentall Procedure in India and UAE | Complete Patient Guide

• ELIGIBILITY — Aortic root aneurysm with root diameter ≥ 5.5 cm in non-syndromic patients (CT angiography or MRI confirmed)

• ELIGIBILITY — Aortic root diameter ≥ 4.5–5.0 cm in patients with Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome (vascular type), or bicuspid aortic valve with associated connective tissue disorder

• ELIGIBILITY — Acute or chronic Type A aortic dissection involving the aortic root, requiring emergency or urgent root replacement

• ELIGIBILITY — Severe aortic valve disease (aortic stenosis with mean gradient > 40 mmHg or aortic regurgitation with LVESD > 50 mm) in the presence of root dilation ≥ 4.5 cm, making isolated valve replacement insufficient

• ELIGIBILITY — Aortic root endocarditis with annular abscess or pseudoaneurysm formation, where valve-sparing or isolated repair is not anatomically feasible

• ELIGIBILITY — Patients with a prior aortic valve replacement who develop subsequent root aneurysm (redo Bentall)

• REQUIRED DIAGNOSTICS — Contrast-enhanced CT angiography of the full aorta (from root to iliacs) for precise diameter measurement, dissection mapping, and surgical planning

• REQUIRED DIAGNOSTICS — Transthoracic echocardiogram (TTE) and intraoperative transesophageal echocardiogram (TEE) to assess ventricular function, valve morphology, and regurgitation severity

• REQUIRED DIAGNOSTICS — Cardiac MRI (CMR) for patients with equivocal CT findings or to assess myocardial fibrosis and aortic flow quantification

• REQUIRED DIAGNOSTICS — Coronary angiography or CT coronary angiography to rule out significant CAD requiring concomitant CABG

• REQUIRED DIAGNOSTICS — Genetic testing (FBN1, TGFBR1/2, COL3A1) for patients under 50 with root aneurysm to identify heritable thoracic aortic disease syndromes

• REQUIRED DIAGNOSTICS — Preoperative risk stratification using EuroSCORE II and the STS Predicted Risk of Mortality (PROM) scoring systems

• REQUIRED DIAGNOSTICS — Complete blood count, coagulation panel (PT/INR, aPTT), renal function (eGFR), liver function, HbA1c (diabetic patients), and group-and-screen

• CONTRAINDICATIONS (RELATIVE) — Severely reduced left ventricular ejection fraction (LVEF < 20%) without reversible etiology; surgical risk must be weighed against heart failure optimization or bridging with LVAD

• CONTRAINDICATIONS (RELATIVE) — Severe, uncorrected coagulopathy or active bleeding disorder

• CONTRAINDICATIONS (RELATIVE) — Advanced renal failure (eGFR < 15 mL/min) not on dialysis — requires nephrology co-management and individualized risk discussion

• CONTRAINDICATIONS (RELATIVE) — Active systemic infection unrelated to the aortic root (surgery should be deferred until infection is controlled)

• CONTRAINDICATIONS (ABSOLUTE) — Patient refusal of surgical intervention with full understanding of rupture/dissection risk (medical management with beta-blockers and ARBs such as losartan is continued in this scenario)

STANDARD BENTALL PROCEDURE (COMPOSITE VALVE GRAFT — MECHANICAL): The classical and most widely performed approach uses a composite graft pre-sewn or hand-sewn with a bileaflet mechanical valve (most commonly On-X or St. Jude Medical Masters Series). The coronary arteries are detached from the native root as 'buttons' of aortic wall tissue and reimplanted directly into pre-cut holes in the Dacron graft — the 'button Bentall' technique, which has supplanted the original inclusion (wrap) technique due to lower risk of late pseudoaneurysm formation. This approach requires lifelong anticoagulation with warfarin (target INR 2.5–3.5). It is preferred for younger patients (< 60 years) who have no anticoagulation contraindications and desire durability without reoperation risk.

BIOPROSTHETIC COMPOSITE GRAFT (TISSUE VALVE BENTALL): For patients over 65 years, women of childbearing age, those with occupational bleeding risk, or patients who decline lifelong anticoagulation, a bioprosthetic tissue valve (Carpentier-Edwards PERIMOUNT Magna Ease, INSPIRIS RESILIA with anti-calcification polymer treatment, or Medtronic Mosaic) is incorporated into the composite graft. The INSPIRIS RESILIA valve features VFit technology, enabling future transcatheter valve-in-valve (TAVR-in-surgical-valve) implantation if structural valve deterioration occurs — a major strategic advantage that eliminates the need for high-risk redo open surgery in elderly patients.

VALVE-SPARING ROOT REPLACEMENT (DAVID PROCEDURE — ALTERNATIVE): For patients under 50 with a structurally normal, pliable aortic valve (tri-leaflet, leaflet height > 17 mm, no commissural fusion) who wish to avoid prosthetic valve and anticoagulation altogether, the David reimplantation procedure (David V technique) is offered at GAF Healthcare partner centers. The native aortic valve is preserved and resuspended within a Dacron tube graft, restoring aortic root geometry. Freedom from reoperation at 10 years exceeds 90% in experienced hands. This is not a Bentall Procedure per se but is the direct alternative and is evaluated case-by-case.

MINIMALLY INVASIVE / MINISTERNOTOMY APPROACH: Selected centers in India and the UAE now offer the Bentall Procedure through an upper (partial) ministernotomy (J-sternotomy or upper mini-sternotomy), limiting the incision to the upper third of the sternum. This approach reduces wound complications, blood loss, ICU stay, and postoperative pain while preserving the mechanical advantages of full sternotomy access. Patient selection requires preoperative CT planning to confirm root accessibility. Not suitable for redo sternotomy cases or those requiring concomitant mitral or tricuspid surgery.

CONCOMITANT PROCEDURES: The Bentall Procedure is frequently combined with: (1) Total arch replacement with elephant trunk technique for aortic arch aneurysm; (2) CABG for concurrent significant coronary artery disease (identified on preoperative coronary angiography); (3) Mitral valve repair or replacement for functional or organic mitral regurgitation; (4) Tricuspid annuloplasty for secondary tricuspid regurgitation. Each addition increases operative time and CPB duration and is factored into individualized risk scoring.

HYBRID AORTIC APPROACHES: For patients with extended aortic pathology (root + arch + descending aorta), a staged hybrid approach is used: surgical Bentall + open arch repair (stage 1), followed by thoracic endovascular aortic repair (TEVAR) for the descending component (stage 2), minimizing the physiological insult of a single prolonged operation.

ANESTHESIA & PERFUSION TECHNOLOGIES: All GAF Healthcare partner sites utilize: (1) moderate hypothermic circulatory arrest (18–22°C) with antegrade selective cerebral perfusion (ASCP) via the right axillary artery to protect the brain during aortic clamping; (2) del Nido cardioplegia for superior myocardial protection; (3) Cell Saver autologous blood conservation; (4) continuous intraoperative TEE; and (5) near-infrared spectroscopy (NIRS) cerebral oximetry for real-time neurological monitoring.

PRE-ARRIVAL PHASE (2–4 weeks before travel):

• GAF Healthcare case manager reviews CT angiography, echo reports, and surgical history to match patient with appropriate surgeon and hospital

• Telemedicine consultation with operating cardiothoracic surgeon to discuss valve choice (mechanical vs. tissue), operative risk (EuroSCORE II / STS PROM), and expected outcomes

• e-Medical Visa application facilitated by GAF Healthcare (India) or tourist/entry visa guidance (UAE — UAE nationals and many GCC passport holders enter visa-free or on visa-on-arrival)

• Travel insurance with cardiac surgical cover obtained; anticoagulation instructions issued if patient is on warfarin or antiplatelet therapy

• Preadmission blood work, ECG, and pulmonary function testing arranged locally or on arrival

DAY 1–2 (ADMISSION & PREOPERATIVE WORKUP):

• Hospital admission; complete in-hospital workup: CT angiography review, TTE/TEE, coronary angiography or CT coronary angiography, full labs, anesthesia consultation

• Surgeon reviews imaging personally; final decision on valve type, conduit size, and need for arch work or CABG

• Informed consent in patient's preferred language (GAF Healthcare medical translator present)

• Bowel preparation, chest physiotherapy orientation, and cardiothoracic ICU familiarization

DAY 3 — THE PROCEDURE (6–9 hours operative time):

• General endotracheal anesthesia with TEE probe placed before skin incision

• Full or partial (ministernotomy) median sternotomy; cannulation of the right femoral artery/axillary artery and right atrium for cardiopulmonary bypass

• Systemic cooling to 18–22°C; aortic cross-clamping; del Nido or cold blood cardioplegia arrest

• Excision of the diseased aortic root and native valve; coronary button mobilization

• Composite graft seated at the aortic annulus with pledgeted horizontal mattress sutures (annular reinforcement with felt strips in patients with Marfan syndrome)

• Left coronary button reimplantation; right coronary button reimplantation

• Distal anastomosis of the Dacron graft to the transected ascending aorta

• Rewarming; weaning from CPB; intraoperative TEE confirming valve function, coronary perfusion, and absence of paravalvular leak

• Chest closure with sternal wires; wound closure

DAY 3–5 (CARDIAC ICU — 2–4 DAYS):

• Mechanical ventilation typically 4–12 hours; early extubation protocol (fast-track cardiac anesthesia)

• Invasive hemodynamic monitoring: arterial line, pulmonary artery catheter or PiCCO; continuous cardiac output monitoring

• Anticoagulation initiated: unfractionated heparin infusion from day 1 postoperatively targeting aPTT 60–80 seconds

• Pain management: IV opioid PCA transitioning to oral multimodal analgesia

• Chest physiotherapy and incentive spirometry from extubation

• Daily ECG, chest X-ray, serum lactate, troponin trend

DAY 5–14 (MONITORED WARD):

• Warfarin initiated (mechanical valve patients) with INR targeting 2.5–3.5; heparin bridge until therapeutic; antiplatelet therapy per surgeon protocol for tissue valve patients

• Ambulation progressively from day 5 (corridor walking with physiotherapist)

• Echocardiogram on day 7 to assess valve function, pericardial effusion, and ventricular recovery

• Dietary counseling on vitamin K-consistent diet (mechanical valve warfarin patients); anticoagulant patient education

• Wound care for sternal incision; sternal precautions education (no lifting > 2 kg for 6–8 weeks)

• Discharge planning with GAF Healthcare case manager: follow-up clinic appointments, pharmacy supply of anticoagulants for journey home

WEEKS 2–8 (POST-DISCHARGE IN-COUNTRY RECOVERY):

• Patients must remain within reasonable distance of the treating hospital for a minimum of 4 weeks post-discharge for mandatory follow-up: wound check at week 2, INR monitoring (2–3x per week initially), and cardiology review at weeks 2 and 4

• Cardiac rehabilitation: supervised walking program, respiratory physiotherapy, progressive aerobic conditioning

• Repeat TTE at week 4 to confirm stable valve function and healing

WEEK 6–8 (FIT-TO-FLY ASSESSMENT):

• Cardiothoracic surgeon and cardiologist jointly assess: stable anticoagulation (INR in therapeutic range for > 2 consecutive weeks), fully healed sternotomy, no signs of mediastinitis or pericardial effusion, LVEF ≥ 45%, and absence of arrhythmia requiring in-hospital management

• Written fit-to-fly certificate issued; compression stocking prescription for long-haul flight; in-flight anticoagulation instructions provided

• GAF Healthcare arranges wheelchair assistance at airport, in-flight medication pack, and coordination with home country cardiologist for continuity of care

LONG-TERM RECOVERY MILESTONES:

• 8 weeks: Return to sedentary or desk-based work

• 12 weeks: Driving (subject to local regulations and surgeon clearance)

• 3–6 months: Return to moderate physical activity; annual aortic imaging (CT or MRI) for remnant aorta surveillance

• Lifelong: Annual cardiology follow-up, INR monitoring (mechanical valve), echocardiography every 1–2 years, and MRI/CT of the entire aorta every 3–5 years to monitor for disease progression in the native aorta