The modified Bentall-de Bono technique, in which the coronary ostia are re-implanted into a tubular prosthesis, while the aortic valve and aortic root are replaced, is the current gold standard for treating ascending aortic pathologies [1].This surgery has seen significant changes over time, such as the switch from the wrap-inclusion approach to the coronary-button technique, and it is now a commonly used standard of care for various aortic root diseases. Perioperative mortality is not negligible, even in skilled hands. It has been suggested to define a risk score, which is already present for coronary and valve surgery, for surgical procedures for the treatment of ascending aorta aneurysms as well [4] .This is because groups that focus on aortic disease have reported a 4–5% mortality rate, a significant incidence of bleeding, and major cardiac and non-cardiac postoperative complications in recent years [11, 12, 14]. Circumferential suture lines on the coronary peri ostium regions and an overall aortic wraparound were used in the original technique to control late intraoperative bleeding. Since then, the rate of problems has dramatically decreased due to the surgeon's increasing experience and technological advancements, such as pre-clotting grafts with albumin, improvements in pump oxygenator systems, and precise heparin modifications [7,8]. To further lower the rate of problems and enhance patient outcomes, a number of modified procedures have also been developed. Nowadays, the preferred procedure in many hospitals globally is the modified Bentall procedure that includes coronary button mobilization. While the modified approaches call for the creation of ostial buttons that are subsequently connected to the graft. Although there have been notable advancements with altered methods, intraoperative blood loss and postoperative complications continue to be a serious challenge.With an emphasis on immediate postoperative outcomes, the present research attempts to assess this modified Bentall's procedure technique for a variety of ascending aortic diseases.

It was a retrospective study conducted at the cardiac surgery department of Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi. Data of patients who underwent modified Bentall operation from January 2018 to August 2024 were retrieved retrospectively from the department database. A total of 60 patients' data were collected. 30 days follow up data was collected.

Inclusion criteria- patient undergoing modified Bentall procedure between January 2018 to July 2024

Exclusion criteria: patient undergoing valve-sparing ascending aortic replacement.

As it is a retrospective study, patient consent was not required.

Surgical technique-

All procedures are carried out via midline sternotomy. In cases of redo sternotomy & dissection, peripheral cannulation was done. In other cases, either Double staged venous cannula or Superior & inferior vena cava cannulation was done. In all cases, Del Nido cardioplegic solution was used. Cold blood Cardioplegia was used for myocardial protection & topical cooling was done with iced slush throughout the procedure. All operations are carried out in moderate to severe hypothermia. In some patients, total circulatory arrest was done in view of the dissection flap being close to the arch vessels. High aortic cannulation was done. Left ventricle vented through Right superior pulmonary vein, & after going to bypass, the aorta is transected. Ostial cardioplegia was given. Aorta incision extended till the level prepared for distal anastomosis. The aortic valve was excised & annulus was measured. The proximal end of the composite graft or the valve sutured to the graft is attached to the aortic cuff. The anastomosis is reinforced with native aortic tissue. Coronary buttons were harvested with at least 5 mm of native coronary tissue. The left coronary button was anastomosed to the graft opening with 6-0 Prolene. Cardio Plegia was delivered by Foleys insufflated into the graft. Distal anastomosis to the conduit with the aorta was done using Prolene 4-0. Distal anastomosis in a dissection patient is reinforced with autologous pericardium. Right coronary buttons anastomosed with conduit using Prolene 6-0. All anastomosis sites are reinforced with biologic glue. Homeostasis achieved & patient weaned from cardiopulmonary bypass.

Statistical analysis-

Data was analysed using SPSS software. The preoperative & postoperative data were summarised using mean & standard deviation from numerical variable.

A total of 60 patients underwent the Modified Bentall procedure from January 2018 to August 2024.

Table-1 : Age distribution

In the present study, most of them are in the 30-39 years age group of 23 (38.3%) members, followed by 20 (33.3%) in the 40-49 years age group,

Table-2: Gender Distribution

The most common comorbidity was Hypertension, present in 10(16.6%) patients. Type 2 diabetes was present in 2(3.3%) patients. Both Hypertension and diabetes were present in 2(3.3%) patients. 46(76.6%) patients had no known comorbidities.

Table-3: Characteristics of the study participants

Table -4 : Comorbidities

Table -5 : Etiology

Table -6 : Cannulation techniques

Table -7 : Surgical details

Table -8 : Associated procedures

We prefer to use mechanical prostheses for patients below 60 years of age. In all cases of our study, we have used mechanical prostheses. The present study is a single-centre experience that includes the etiology of dilated ascending aorta & aortic dissection.In a meta-analysis done by Mookhoek et al, the mean age of patients undergoing the Bentall procedure was 49.8 years, with a range of 29-65 years of age. Males were predominant over females with a ratio of 2:1. Hypertension was the most common risk factor associated. Bicuspid aortic valve is associated with 24.9 % of patients [5] . Several other factors, such as atherosclerosis, Marfan syndrome, and diabetes, are associated with aneurysm & dissection of the aorta. This study differs from the study done by Mookhoek et al [5] , in that aortic dissection is associated with 15.3% patients, whereas in our study, it is associated with 30 % of cases. Emergency operations were done in 15.8 % of patients, whereas in our study, they were done in 23.3% of cases.In a study by Nardi et al , a concomitant procedure was done in 26.7% patients, out of which CABG was done in 16% of patients [4]. In our study, concomitant procedure was done in 10(16.6%) patients, with Coronary artery bypass grafting was done in 4(6.6 %) of patients. Other methods include Alfieri stitch for mitral valve repair, pulmonary thromboendarterectomy, mitral valve replacement, aortic conduit to Descending thoracic aorta tube graft anastomosis for coarctation of the aorta was done. In a study done by Mudhaffar et al , which included 77.7% aortic dissection patients with associated procedures in 16% patients, the mean bypass time was 310 min & aortic cross clamp time was 220 mins [15]. In our study with 30% patients operated for aortic dissection, with concomitant procedures done in 16.6 % of patients, the mean bypass time is 283 min & mean aortic cross clamp time is 213 min.In our study, all patients had mechanical composite grafts or conduits. In aortic dissection patients, we used axillary cannulation with antegrade cerebral perfusion. In 4 (6.6%) patients, we have used femoral arterial cannulation & 2 (3.3%) patients, we have used right carotid arterial cannulation.  In Mookhoek et al., the meta-analysis suggests that re-exploration in 6.7 % of patients is caused by bleeding [5]. In our study, reexploration was done in 5(8.3%) of patients, out of which four patients had bleeding & 1 had air leak from the left intercostal chest tube. Three patients had delayed sternal closure in view of borderline hemodynamics post-surgery. 2 patients had hepatic dysfunction postoperatively, which was managed medically. Three patients had complete heart block requiring permanent pacemaker placement in the immediate postoperative period. All cause mortality in our study is 7(11.6 %), of which elective cases have a mortality of 3(6.5%) & emergency cases have a mortality of 4 (28.5%). A study by Mookhoek et al.  suggested early mortality is 5.6%, whereas emergency procedures are 15.3% [5]. A study done by Yang et al  suggested overall mortality of 13% & composite mortality of 23% in the Bentall procedure in aortic dissection patients [16]. Out of 7 mortality, three patients had undergone concomitant CABG out of which two reexplored given haemorrhage from distal anastomotic site, one patient had history of grade 5 CKD, who post operatively re explored in view of grade 4 air leak from right intercostal chest tube following permacath insertion in right IJV. The cause of the three patients' mortality was unknown.

Strict postoperative care is strongly recommended for patients undergoing the modified Bentall procedure. Despite numerous modifications, postoperative bleeding and thromboembolism are dreaded complications for these subsets of patients. Lack of uniform census for operative procedure is the key to improving outcomes in these patients.

Modified Bentall procedure can be considered the gold standard for different types of ascending aortic root pathologies, being associated with low rates of operative mortality in elective cases. Only the Bentall procedure can be considered in patients presenting with aortic dissection with complications.Preoperative low cardiac output syndrome with NYHA III/IV is associated with poor outcome.

Limitations of the Study

This study is limited by its retrospective design. Additionally, the single-center design limits the generalizability of the results to other settings with different patient populations or surgical practices. Further studies with larger, multicenter cohorts would strengthen the findings and allow for a more detailed understanding of outcomes across diverse populations.

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