Bentall Surgery for Infective Endocarditis: A Biointegral Bioconduit Subannular Implantation

Bentall surgery, often required in patients with an aortic valve prosthesis infection, represents a great surgical challenge. Extensive periannular abscess with annular destruction and friable infected tissues may hamper a solid root reconstruction. Graft dehiscence, mitral valve distortion or dysfunction, and tension or kinking at the reimplanted coronary arteries represent the major technical concerns in this setting.With the present video, the authors share the approach they use at the department of Cardiac Surgery in Ancona, Italy, to treat patients requiring Bentall surgery for infective endocarditis (IE). This involves a subannular implantation technique and the use of a 100% pericardial valved conduit (Biointegral Bioconduit).In detail, the authors use four to five subannular "U stitches" for each sinus, reinforced with a pericardial strip. With this very low suture line, by taking only a few millimeters of the anterior mitral leaflet and anteriorly the muscular septum, they keep the abscess draining outside—into the pericardial cavity—and deliberately renounce reconstructing the annulus, which may generate tension on the friable anatomical structures thus causing graft dehiscence.In this challenging scenario, the 100% pericardial Biointegral Bioconduit plays a central role and, compared to other conventional stented composite grafts, may add important advantages in IE patients. In fact, the Bioconduit pliability (a) allows itself to adapt very well to the irregular annular surfaces that are often found in IE, and (b) reduces the mechanical stress that is applied to the sutured friable tissues during the cardiac cycle. Such characteristics contribute to minimizing the risk of leak, dehiscence, and anterior mitral leaflet distortion, allowing for a very solid and hemostatic root reconstruction.A Biointegral Bioconduit implantation, performed as a third intervention in an 82-year-old man with IE, is shown and discussed in the video.Suggested ReadingAnguera I, Miro JM, Cabell CH, et al. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol. 2005;96(7):976-981.Guenther SP, Reichelt A, Peterss S, et al. Root replacement for graft infection using an all-biologic xenopericardial conduit. J Heart Valve Dis. 2016;25(4):440-447.Okada K, Okita Y. Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis. Gen Thorac Cardiovasc Surg. 2013;61(4):175-181.