Institutional Learning Curve over Two Decades for Complex Procedures Leads to Excellent Contemporary Results: 782 Bentall Procedures

Objectives: Aortic root replacement with reattachment of the coronaries was originally described by Bentall and de Bono with several alterations during the past decades. However, early mortality is 5% and has not changed over the years. In the past decade, fast-track concept has been implemented in cardiac surgery.

Methods: Our institutional database was retrospectively reviewed over an 18-year period, from January 2000 to August 2018. Patients with concomitant procedures and previous cardiac surgery were excluded. A total of 782 patients underwent elective isolated (modified) biological or mechanical Bentall procedures and were compared in two timeframes: 2000 to 2008 and 2009 to 2018, before and after implementation of the fast-track concept. Chi square, unpaired t-test, unpaired Welch’s t-test, Wilcoxon’s signed-rank test, Kaplan–Meier, and Cox regression were utilized. The regression model was chosen based on outcome data type between binomial logistic regression and cox-proportional hazards regression.

Results: Age of the patients did not change over the years (60.19 ± 12 vs. 59.42 ± 13; p = 0.4), but comorbidities increased significantly: arterial hypertension (87 vs. 69%), pulmonary hypertension (23 vs. 3%), and hyperlipidemia (45 vs. 32%); p < 0.001. In recent years, patients received more biological Bentall (73 vs. 61%, p < 0.001). Over time, length of cross-clamp time, bypass time, and length of surgery did not change significantly. However, during the past 10 years, median ventilation time (5.76 [9.1–13.0] vs. 12.96 [9.4–18.5] hours, p < 0.001), ICU stay (18.24 [6.0–25.2] vs. 21.12 [14.6–25.7] hours, p = 0.002), and IMCU stay (27.12 [18.5–67.7] vs. 37.92 [22.8–73.2] hours, p = 0.005) were significantly shorter, compared to 2000 to 2008. Reoperations for bleeding (7.8 vs. 3.1%, p = 0.05) as well as in-house mortality (2.8 vs. 0.9%, p = 0.06) could be reduced. No difference on early and long-term mortality for the different time periods could be detected in regression model.

Conclusion: Management of patients receiving modified Bentall procedure improved over time leading to shorter ICU/IMCU times and excellent in-hospital mortality. Fast-tract concept can be applied to complex aortic surgery without negative impact on postoperative complication rate.