The Bentall–De Bono aortic root replacement remains the reference technique for patients with aortic root dilatation associated with severe aortic regurgitation. Its reproducibility is high and clinical outcomes are excellent. Nevertheless, the initial anastomotic plane between the native root and the graft continues to represent a critical step, where bleeding and excessive tension may compromise the result.

In this CTSNet video, Heilbron O. demonstrates a focused modification of the Bentall procedure that deserves close attention. The resource is concise and highly illustrative (just over 3 minutes), concentrating exclusively on improving the proximal anastomosis through a double mattress-type suture technique. All other steps remain identical to the standard Bentall approach, which makes the learning objective particularly clear.

At minute 01:05, the modification begins. Approximately 1 cm of native aorta above the valvular annulus has been preserved, and the aortic valve has already been excised. Along this edge, the surgeon places a continuous line of interrupted pledgeted sutures (min 1:05), wide and transmural, passing from outside to inside through the aortic wall and exiting below the annulus, with the pledgets remaining on the external surface. Each suture is then passed through the sewing cuff of the valved conduit, progressing circumferentially around the annulus. Once all sutures are in place, the graft is seated down to the anastomotic plane. Subsequently, each suture is exteriorized again (min 1:55), this time at a higher level, converting them into mattress sutures and creating a double compressive layer around the residual aortic annulus, approximately 1 cm above the initial plane. This results in a firm and homogeneous seal, while carefully avoiding compromise of the coronary ostia.

After completing the circumference, the sutures are tied, yielding a secure, watertight anastomosis with a clean final appearance.

The final result aims to achieve three clearly surgical objectives:

1. To use the residual aortic edge in contact with the prosthesis to enhance sealing at the aortoventricular junction.

2. To distribute tension evenly, reducing the risk of tearing in potentially fragile tissue.

3. To simplify hemostasis, minimizing the need for additional reinforcing sutures or adjunctive sealants.

The educational value of the video lies precisely in this clarity. It avoids distraction from coronary variations or additional reinforcement maneuvers. The proposal is as straightforward as it is useful: preserve the standard Bentall–de Bono strategy while incorporating a more intelligent sealing approach at the prosthesis–aortoventricular junction interface.

COMMENTARY:

This modification aligns with a concept that every surgeon appreciates: when a technique works very well but still has room for improvement at a specific step, it is worth refining it rather than reinventing it. The “mattress-type” suture offers improved watertightness and appears more forgiving in delicate tissues, while preserving a simple and reproducible execution.

It may be particularly valuable in scenarios where tissue vulnerability is increased, such as in patients with thinned aortic edges due to infectious or degenerative processes, as well as in redo procedures, where prior manipulation has already compromised the aortic wall. Its use also seems reasonable in situations requiring rapid and effective hemostasis, as the added circumferential compression could reduce the need for subsequent reinforcement. Indeed, gaining access to reinforce the transition between the valved conduit and the aortoventricular junction can be technically demanding, both with conventional approaches and especially when minimally invasive strategies are employed. For this reason, it is a step that must be performed once—and done well.

This technique does not solve every challenge associated with the Bentall procedure, nor does it attempt to. It represents a practical refinement of a maneuver repeated countless times over a surgical career. That may well be its greatest strength.

REFERENCE:

Heilbron O. The Bentall-de Bono Procedure: A Novel, Time-Efficient Mattress-Type Technique for Aortic Root Anastomosis. October 2025. doi:10.25373/ctsnet.30456152