Replacement of the ascending aorta and aortic valve for Annuloaortic ectasia with Carbomedics Carbo-seal ValsalvaTM graft: mid- to long-term results

Replacement of the ascending aorta and aortic valve for Annuloaortic ectasia with Carbomedics Carbo-seal ValsalvaTM graft: mid- to long-term results | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Replacement of the ascending aorta and aortic valve for Annuloaortic ectasia with Carbomedics Carbo-seal ValsalvaTM graft: mid- to long-term results Raif Cavolli, Dogan Kahraman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6671320/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose The modified Bentall procedure (MBP) employing the Carbomedics Carbo-seal Valsalva™ graft may be used to treat patients with annuloaortic ectasia. In this study we focused on patients who underwent MBP to treat annuloaortic ectasia. Our goal was to review the outcomes of these surgeries over a long period. Methods From 2012 to 2024 48 consecutive patients with annuloaortic ectasia underwent aortic root replacement with Carbomedics Carbo-seal Valsalva™ graft. Concomitant cardiac procedures were performed in 7 patients (MBP+Mitral valve annuloplasty, 2 patients and MBP+Coronary artery bypass grafting, 5 patients). Mean Cardiopulmonary bypass and aortic clamp time for were 151±37 and 128±14 minutes, respectively. Results The operative mortality was 2.1% (n = 1). Late causes of death were chronic heart failure (1 patient, 2.1%), cerebral haemorrhage (1 patient, 2.1%) and pulmonary complications (1 patient, 2.1%). And major late complications included cerebral hemorrhage in 2 patients (4.2%), cerebellar ischemia in 1 patient (2.1%) and gastrointestinal hemorrhage in 2 patient (4.2%). Kaplan-Meier estimated survival rates for 5 and 10 years were 96.22% and 95.20% respectively. The Kaplan-Meier curves showed event-free survival at 5 and 12 years 98% and 82%, respectively (CI 95%). Conclusions MBP operations for annuloaortic ectasia, with Carbomedics Carbo-seal Valsalva™ graft, can be performed with a low mid- and long-term mortality and morbidity in low-volume centers. Modified Bentall procedure aortic root replacement aortic surgery Figures Figure 1 Figure 2 Introduction Bentall and DeBono were the first to report using the composite graft and valve to replace an ascending aortic aneurysm and aortic valve over 50 years ago. For coronary artery reattachment, they used in situ circumferential suture lines around the coronary ostia, and to control bleeding they wrapped the native aortic wall around the prosthesis[1]. In response to evidence of increased risk of pseudoaneurysm development and of coronary compression or detachment due to oozing within the perigraft space, technical variations, such as the Cabrol modification, have been introduced[2]. However, the Cabrol carries the risk of thrombosis of the interposed Dacron conduits. Today's most commonly performed variant for root replacement is the “button” technique of Kouchoukos and colleagues[3]. This method has proved effective in avoiding tension on the coronary anastomoses, thereby preventing excessive bleeding and kinking of the coronary arteries. In this study, we want to share our experience of over 10 years with the MBP using Carbomedics Carbo-seal Valsalva TM graft. This surgery involved making certain modifications to the traditional Bentall operation, and we carefully observed the outcomes. By studying the results of these surgeries, we aimed to gain a better understanding of the effectiveness and safety of using the Carbomedics Carbo-seal Valsalva TM graft in this operation. Our main focus was on the survival rates of individuals in the later stages of their lives and the occurrence of significant complications that may arise during this period. We carefully monitored these factors for a maximum duration of 12 years. Patients and methods This retrospective observational study approved by the instutional ethics board (Nr. 1012). All patients were informed about the procedure and provided written consent of the operation. The study was conducted under the Declaration of Helsinki. All operations were carried out from September 2012 to January 2024 in 2 different centers by same operative team and same primary surgeon. 48 patients with annuloaortic ectasia (sinotubular diameter/annular diameter ratio ≥ 2) underwent MBP with Carbomedics Carbo-seal Valsalva™ graft. Annuloaortic ratio was measured via preoperative echocardiograohy and tomographic angiography. None of the patients were definitively diagnosed with Marfan syndrome; nevertheless, five individuals displayed characteristics consistent with Marfanoid features. Patients needing non-elective surgery (acute type A aortic dissection, 9 patients) and those with endocarditis (2 patients) were excluded from the study. Data were collected by the cardiac surgeon with a properly designed form sheet. The characteristics of patients such as age, gender, related comorbidity, metabolic disorder, cardiovascular diseases, and relevant risk factors were collected. Operative technique All surgical approaches were through a median sternotomy. All operations were performed with the aid of cardiopulmonary bypass (CPB) instituted using atrial drainage and cannulation of the distal ascending aorta, or right axillary artery if proximal arch involved, for arterial return. To prevent potential retrograde thromboembolic events, we decided to avoid femoral cannulation. Axillary cannulations were performed by direct insertion of arterial cannula instead of sewing a side arm-graft. Circulatory arrest (CA) was instituted in 4 patients just after lowering the vesical temperature to 22–26°C. The cerebral protection was maintained by moderate hypothermia with anterograde cerebral perfusion (ACP) during CA. Near-infrared spectroscopy (NIRS) for Intraoperative cerebral monitoring, and simultaneous radial artery pressure measurement of both arm were mandatory. In 4 cases necessitating selective ACP, innominate and left subclavian artery were clamped and then graft to aorta anastomosis was openly performed after excising diseased arch segment. Antegrade or retrograde cold blood cardioplegia (or both, if extensively diseased coronary arteries present) was used for myocardial protection. Composite conduits were implanted using the same technique throughout the study period: excision of the native valve and preparation of the coronary buttons were followed by implantation of composite graft to the annulus using interrupted U sutures of pledgeted 2 − 0 polyester. A running suture of 3 − 0 prolene was used to stitch the remnants of aorta surrounding the native annulus to the sewing ring of the graft to provide better hemostasis. First the left and then the right coronary button anastomoses were performed using 5 − 0 prolene. Distal end of the graft was sewn to the distal aorta with externally lied teflon strip over the anastomosis line. Before aortic clamp removal, we connected a vacuum suction line to the aortic vent while applying fibrin glue to the anastomosis line. The patients were weaned from CPB after rewarming and air evacuation. Postoperative Follow-up Before leaving the hospital, all patients had to undergo a clinical evaluation with routine laboratory and transthoracic echocardiogram. The patients were scheduled to engage follow-up visits at different intervals. These intervals included 1st month, 3rd months, 6th months, and at the end of 1st year. The total follow-up time of patients is 1963 patients/year. Long-term anticoagulation was maintained with a target international normalized ratio (INR) of 2-2.5. They are specifically informed about the need to receive computed tomography (CT) angiography within the first year after the procedure. Study endpoints The study endpoints are: (1) mid- and long-term mortality; (2) mid- and long-term morbidity; and (3) in-hospital freedom from all-cause major adverse events as defined according to the established guidelines. During long-term follow-up, it was also recorded whether patients developed a documented noncardiac co-morbidity that resulted in death. Statistical analysis Continuous data are expressed as mean ± 1 SD or median; categorical variables are reported as a percentage; a commercial statistical software package (SPSS for Windows, version 25.0, SPSS Inc, Chicago, Ill) was used for data analysis. Analysis of the actuarial survival curve was performed by use of the Kaplan-Meier estimation for freedom from death and freedom from major complications. Results Preoperative data A total of 48 patients underwent a modified Bentall procedure. The baseline characteristics of these patients are summarized in Table 1 . There were 40 males (84%), with a mean age 61.64±5.85. Preoperatively, 7 patients were in New York Heart Association (NYHA) functional class II, 29 in Class III, and in Class IV were 12 patients. Table 1 Preoperative Characteristics BMI: body mass index, AR: aortic regurgitation Characteristics Age 61.64±5.85 Gender(M) 40(83.3%) NYHA functional class I 0 II 7(14.6%) III 29(60.4%) IV 12(25%) Left Ventricular Ejection Fraction ≥60% 16(33.3%) Between 59% − 40% 27(56.2%) ≤39% 5(10.4%) Coronary artery disease 5(10.4) Chronic obstructive pulmonary disease 1(2.1%) Atrial fibrillation 3(6.2%) Smoking 25(52.1%) Hypertension 26(54.2%) Cerebrovascular accident 3(6.25%) Diabetes mellitus 20(41.6%) Obesity (BMI>30) 12(25%) Chronic lung disease 15(31.2) Myocardial infarction 5(10.4%) Chronic renal failure 2(4.2%) Aortic valve disease Moderate AR 10(20.8%) Severe AR 32(66.7%) Stenosis + Regurgitation 6(12.5) Ascending Aorta(cm) 63,6±8 Operative and Early results There was one hospital death due postoperatively diagnosed von Willebrand disease and excessive hemorrhage. The bleeding resulted in multi-organ failure and he was lost at 6th day after the operation (2.1%). Carbomedics Carbo-seal Valsalva™ composite grafts were used in all patients (100%). The valve sizes were 23 mm (4 patients; 8.33%), 25 mm (30 patients; 62.5%), 27 mm (12 patients; 25%), and 29 mm (2 patients; 4,16%). A standard MBP was performed in the vast majority of patients (n = 44; 91,6%) while 4 patients (8,4%) had additional hemiarch replacement. Concomitant procedures were performed in 7 patients (14,58%) as Mitral valve repair in 2 patients (4,16%) and coronary artery bypass grafting in 5 patients (14,58%). Except 6 cases (12.5%) necessitating axillary site for diseased arch, arterial cannulation was mostly through the ascending aorta. We conducted deep circulatory arrest with antegrade SCP in only four patients. The mean CPB time was 168.45 ± 37.36 min, and the mean aortic cross-clamp time was 128.64 ± 14.36 min. Mean of bleeding was 750 ml (min. 450 ml, max. 5600 ml). Surgical re-exploration for bleeding was needed in only one patient (preoperatively undiagnosed von Willenbrand patient). Further, perioperative characteristics are shown in Table 2 . No patients experienced respiratory complications requiring prolonged ventilation, endocarditis, or pericardial effusion. Table 2 Perioperative characteristics Cross-clamp time(min.) 129±14 Perfusion time(min.) 151±14 Total circulatory arrest(min.) 25±5 Total circulatory arrest(n) 4(8.33%) Bleeding (ml) 750(min. 450 ml, max. 5600 ml)-included Von Willenbrand patient Reoperation for bleeding 1(2.1%) Hospital Death 1(2.1%) Cause of hospital death Von Willebrand disease 1(2.1%) 30-day mortality 1(2.1%) ICU stay (days) 4.2±2.5 Hospital stay(days) 10.0±4.4 Concomitant procedures Mitral valve repair 2(4.2%) Coronary artery bypass surgery 5(10.42%) Prosthesis size (mm) 23 4 (8.33%) 25 30 (62.5%) 27 12 (25%) 29 2 (4.16%) Late results Mortality The summary of postoperative mortality can be found in Table 3 . There were 4 deaths, with an overall mortality of 8.3%. Three deaths were observed in late follow-up. The causes of death (6.38%) was chronic heart failure, cerebral hemorrhage and pulmonary complications. The aortic valve-conduit did not directly cause mortality. Figure 1 shows the results of the Kaplan-Meier analysis regarding freedom from all-causes death at 5 and 12 years were 97% and 93%, respectively (CI 95%). Table 3 Early and late results 30-day death cause Von Willebrand disease 1 Late death causes Chronic heart failure 1 Cerebral hemorrhage 1 Pulmonary complications 1 Major anticoagulant-related events Cerebral hemorrhage 2 Cerebellar ischemia 1 Gastrointestinal hemorrhage 2 Morbidity Postoperative complications are presented in Table 3 . One patient, who underwent concomitant MBP surgery and mitral valve repair, had symptoms of cerebellar ischemia on the 14th day. Symptoms resolved five days later with medical treatment. Four patients suffered different types of bleeding due to high INR level: two had a cerebral haemorrhage, one experienced gastrointestinal haemorrhage, and another had hemoptysis. Figure 2 shows the results of the Kaplan-Meier analysis regarding freedom from all causes of late complications during the follow-up period. The Kaplan-Meier curves showed event-free survival at 5 and 12 years 98% and 82%, respectively (CI 95%). Discussion The main finding of this study is that aortic root replacement with Carbomedics Carbo-seal Valsalva™ graft for dilated aortic root in a low volume center provides an acceptable clinical outcome with low mid- and long-term complication rates. Although more than 20% of them had undergone an additional intervention (hemiarch, mitral and coronary surgery), patients at sixties had achieved 93% of survival rate throughout following 12 year. Untreated aortic root dilatation may culminate in life-threatening acute aortic dissection or rupture [ 4 , 5 ]. Bentall inclusion technique with various modification, became the standard practice for surgical treatment of anuloaortic ectasia for many years. Bleeding, perioperative myocardial infarction, right ventricular dysfunction, heart rhythm, low cardiac output, heart attack, stroke, infection, cute renal failure, prolonged mechanical ventilation, new pseudoaneurysm, tromboembolism or dissection of the aorta are still cause of mortalty and the morbidity [ 6 , 7 , 8 ]. Surgical modifications and use of newly designed grafts are being performed and published worldwide to manage these complications [ 9 , 10 ]. As an additional technical modification, just before removing aortic clamp we connected the vacuum line to venting cannula to prevent oozing blood while applying a fibrin sealant around anastomosis line. Since it has been performed for decades even in small clinics, The technical details of the Bentall procedure are well deliniated (sequential suturing of valve ring, left coronary button, right coronary button and distal aortic anastomosis) and achieving individual expertise is comperably easier than valve spearing root procedure. The Carbomedics Carbo-seal ValsalvaTM composite graft has has a vertical oriented pleats at valsalva portion alloving accurate targeting and easy anastomosis of the coronary buttons [ 10 , 11 ]. Besides, the theoretical benefits of using the Valsalva graft includes: less mobilization and dissection of coronary sinüs to implant valsalva graft, offering less tension and less probability of kinking or rotation comprimising coronary flow. It also creates eddy current in aortic root is favoring coronary supply, promoting valve closure and decreasing thrombotic affinity [ 11 ]. We believe that these factors have contributed to keep early postoperative complications at acceptable range in our narrow patient population. 2.1% mortality (due to postoperative diagnosis of vWD and eventual death) and one thrombotic cerebral event is comperable with recent reports including valve sparing and biograft surgeries. The evidence presented is concordant to the inferences reported in the guideline by American Heart Association and American College of Cardiology in 2022[ 12 ]. Current guidelines and large scale studies recommend valve-sparing surgery and bioprosthetic conduits for selected subgroup to avoid thromboembolic complications caused by mechanical valves [ 12 , 13 , 14 ]. Bioprostheses are quite expensive, and also valve-sparing surgery carries appearent risk early failure especialy during learning curve. Moreover, the considerable amount late failure necessitating the valve-in-valve reintervention increases the cost of wellbeing after the root repair for a low flow center. The patients requiring aortic root surgery in the developing countries are getting older and that is concordant to countries of the West. However, the resources for health financing does not show parallel expanse. We actually may have hesitated to do valve-sparing surgery, because the learning curve for AVS surgery is steep and unforgiving of even small technical errors, it is challenging to master the art of AVS surgery and maintain successful and durable outcomes in low-volume centers [ 16 ]. The overall late mortality rate in our study is 6.25%. We found that none of the patients in this series required further treatment for cardiac issues such as endocarditis or valve dysfunctions. Based on our experience, we have found that the MBP can be conducted with minimal risks and complications. This surgical procedure has a low rate of both mortality and morbidity, meaning that the chances of death or post-operative complications are significantly reduced. The modified Bentall procedure is likely to remain the standard approach for this disease, despite valve-sparing procedures having gained increasing popularity to correct aortic regurgitation caused by aortic root pathology[ 15 ]. Regardless of underlying disease the Bentall may also be the most appropriate choice in low flow clinics. Experiences suggest that the early appearance of aortic insufficiency after a valve-sparing operation leads rapidly to progressive hemodynamic deterioration, making it a riskier alternative than a Bentall procedure in the presence of severe preoperative myocardial dysfunction. Patients with moderate or severe preoperative aortic insufficiency may experience less favorable outcomes after valve-sparing surgery compared to those with mild aortic regurgitation[ 15 , 16 , 17 ]. The use of composite graft with mechanic valve obligates anticoagulation. Even though closer follow-up of those decent population is possible in a small country, we still experienced six events that were directly related to warfarin. The introduction of home testing of coagulation status offers a new opportunity for improved follow-up of patients undergoing mechanical valve replacement. Furthermore, Schmidtke and coworkers demonstrated that self-management of anticoagulation leads to a superior quality of life after mechanical valve replacement compared with conventional physician-monitored anticoagulation[ 18 ]. Limitations When analyzing the findings of this study, it is important to consider some limitations. Firstly, our study is conducted retrospectively. In addition, it is important to note that the study conducted was limited to only one team, without the control group. As a result, it was limited by the relatively small number of patients included. Despite these limitations, our study provides long-term outcomes in patients who underwent aortic root replacement with Carbomedics Carbo-seal Valsalva™ composite grafts. Conclusion In conclusion, the study shows that the rates of mortality and morbidity after MBP with Carbomedics Carbo-seal Valsalva™ composite grafts over a long period were similar to those in other research studies. Easly established classic surgery with low cost may still continue to be in use for elderly yielding comperable outcomes in both the short term and the long term. However, anticoagulation-related complications continue to pose a significant challenge that needs to be addressed effectively. It is crucial to prevent and manage these complications carefully to ensure patient safety. Declarations Funding None Author contribution RC: Conception, Design of the work, Acquisition, analysis, Interpretation of data, Writing DK: Writing-review and editing All authors read and approved the final manuscript. Competing interest The authors declare no competing interests References Bentall HH, de Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23:338–9. Cabrol C, Pavie A, Gandjbakhch I, Villemont JP, Guiraudon G, Lauglin L, et al. Complete re-placement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg. 1981;81:309–15. Kouchoukos NT, Wareing TH, Murphy SF, Perillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg. 1991;214:308–18. discussion 318–320. Davies RR, Goldstein LJ, Coady MA, Tittle SL, Rizzo JA, Kopf GF, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. AnnThorac Surg. 2002;73:17–27. Kim JB, Spotnitz M, Lindsay ME, MacGillivray TE, Isselbacher EM. Sundt 3rd TM: Risk of aortic dissection in the moderately dilated ascending aorta. J Am Coll Cardiol. 2016;68:1209–19. Hagl C, Strauch JT, Spielvogel D, Galla JD, Lansmanc SL, Squitieri R, et al. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Ann Thorac Surg. 2003;76:698–703. discussion 703. Pratali S, Milano A, Codecasa R, De Carlo M, Borzoni G, Bortolotti U. Improving hemostasis during replacement of the ascending aorta and aortic valve with a composite graft. Tex Heart Inst J. 2000;27(03):246–9. Joo HC, Chang BC, Youn YN, Youn YN, Yoo KJ, Lee S. Clinical experience with the Bentall procedure: 28 years. Yonsei Med J. 2012;53(5):915–23. Mookhoek A, Korteland NM, Arabkhani B, Di Centa I, Lansac E, Bekkers, et al. Bentall procedure: a systematic review and meta-analysis. Ann Thorac Surg. 2016;101(5):1684–9. Yakut C. A new modified Bentall procedure: the flanged technique. Ann Thorac Surg. 2001;71:2050–2. De Paulis R, Salica A, Pisani G, Morbiducci U, Weltert L, Maselli D. Hemodynamics of aortic valve and root: implications for surgery. Ann Cardiothorac Surg. 2013;2:40–3. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146. Lechiancole A, Vendramin I, Sponga S, Piani D, Benedetti G, Meneguzzi M, et al. Bentall procedure with the CarboSeal ™ and CarboSeal Valsalva ™ composite conduits: long-term outcomes. Interact CardioVasc Thorac Surg. 2021;33:93–100. Bortolotti U. Avoiding Bleeding in the Modified Bentall Procedure. Aorta(Stamford). 2021;9(2):92–3. de Kerchove L, Boodhwani M, Glineur D, Vandyck M, Vanoverschelde JL, Noihomme P, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430–8. David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg. 2017;153:232–8. Luciani GB, Casali G, Tomezzoli A, Mazzucco A. Recurrence of aortic insufficiency after aortic root remodeling with valve preservation. Ann Thorac Surg. 1999;67:1849–52. Schmidtke C, Huppe M, Berndt S, Notzold A, Sievers HH. Quality of life after aortic valve replacement. Self- management or conventional anticoagulation therapy after mechanical valve replacement plus pulmonary autograft. Z Kardiol. 2001;90:860–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6671320","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486128176,"identity":"4b5c929e-c296-47bf-b547-0ec1b6a33a92","order_by":0,"name":"Raif Cavolli","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYFACxoYPYJqdueEAiMXGTlhL4wwwzczYcBDEYmMmwhq4FmYeMIOAevP2w40NDDV2if3MjI2HbX5tk+djZmD88DEHtxaZM4lALceSE2c2MzYczu27bdjGzMAsOXMbbi0SDIntD4BOMjY4DNLSc5sRqIWNmRefFv6HjQ2MDfUQLZY9t+0Ja5FIBGk5LAfWwvDjdiIRWoC2JBw7LicJ9MvB3obbyW3MjM34/cKf/rDhQ001Dz978+EPP/7ctp3f3nzww0c8WsAgAcZgbAOTDQTUo4A/pCgeBaNgFIyCkQIABDhQos0GevcAAAAASUVORK5CYII=","orcid":"","institution":"United Hospital, Kosovo","correspondingAuthor":true,"prefix":"","firstName":"Raif","middleName":"","lastName":"Cavolli","suffix":""},{"id":486128177,"identity":"9fb8df21-c242-4185-a624-2efa13cf5fc9","order_by":1,"name":"Dogan Kahraman","email":"","orcid":"","institution":"Kocaeli Üniversitesi Araştırma ve Uygulama Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Dogan","middleName":"","lastName":"Kahraman","suffix":""}],"badges":[],"createdAt":"2025-05-15 09:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6671320/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6671320/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87318054,"identity":"3b9f9982-67d7-4b3d-b014-8ca8bdae2550","added_by":"auto","created_at":"2025-07-22 16:14:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12102,"visible":true,"origin":"","legend":"\u003cp\u003eThe results of the Kaplan-Meier analysis regarding freedom from all-causes death at 5 and 12 years were 97% and 93%.\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-6671320/v1/dfca824bd7a59482a334139f.png"},{"id":87319556,"identity":"3adc9095-f9a9-457a-9e3e-3567eceec667","added_by":"auto","created_at":"2025-07-22 16:22:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":7531,"visible":true,"origin":"","legend":"\u003cp\u003eThe Kaplan-Meier curves showed event-free survival at 5 and 12 years 98% and 82%, respectively (with confidence intervals 95%).\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6671320/v1/a7b0e74b290fb52ee6889523.jpg"},{"id":92205936,"identity":"8090287d-5d3f-4fc0-86b0-18a9bf02bad2","added_by":"auto","created_at":"2025-09-25 18:31:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":552839,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6671320/v1/3c0f0c11-5edf-4937-a960-a5f4aae17b0e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Replacement of the ascending aorta and aortic valve for Annuloaortic ectasia with Carbomedics Carbo-seal ValsalvaTM graft: mid- to long-term results","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBentall and DeBono were the first to report using the composite graft and valve to replace an ascending aortic aneurysm and aortic valve over 50 years ago. For coronary artery reattachment, they used in situ circumferential suture lines around the coronary ostia, and to control bleeding they wrapped the native aortic wall around the prosthesis[1].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eIn response to evidence of increased risk of pseudoaneurysm development and of coronary compression or detachment due to oozing within the perigraft space, technical variations, such as the Cabrol modification, have been introduced[2]. However, the Cabrol carries the risk of thrombosis of the interposed Dacron conduits. Today\u0026apos;s most commonly performed variant for root replacement is the \u0026ldquo;button\u0026rdquo; technique of Kouchoukos and colleagues[3]. This method has proved effective in avoiding tension on the coronary anastomoses, thereby preventing excessive bleeding and kinking of the coronary arteries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, we want to share our experience of over 10 years with the MBP using Carbomedics Carbo-seal Valsalva\u003csup\u003eTM\u003c/sup\u003e graft. This surgery involved making certain modifications to the traditional Bentall operation, and we carefully observed the outcomes. By studying the results of these surgeries, we aimed to gain a better understanding of the effectiveness and safety of using the Carbomedics Carbo-seal Valsalva\u003csup\u003eTM\u003c/sup\u003e graft in this operation. Our main focus was on the survival rates of individuals in the later stages of their lives and the occurrence of significant complications that may arise during this period. We carefully monitored these factors for a maximum duration of 12 years.\u0026nbsp;\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e This retrospective observational study approved by the instutional ethics board (Nr. 1012). All patients were informed about the procedure and provided written consent of the operation. The study was conducted under the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eAll operations were carried out from September 2012 to January 2024 in 2 different centers by same operative team and same primary surgeon. 48 patients with annuloaortic ectasia (sinotubular diameter/annular diameter ratio\u0026thinsp;\u0026ge;\u0026thinsp;2) underwent MBP with Carbomedics Carbo-seal Valsalva\u0026trade; graft. Annuloaortic ratio was measured via preoperative echocardiograohy and tomographic angiography. None of the patients were definitively diagnosed with Marfan syndrome; nevertheless, five individuals displayed characteristics consistent with Marfanoid features. Patients needing non-elective surgery (acute type A aortic dissection, 9 patients) and those with endocarditis (2 patients) were excluded from the study.\u003c/p\u003e \u003cp\u003eData were collected by the cardiac surgeon with a properly designed form sheet. The characteristics of patients such as age, gender, related comorbidity, metabolic disorder, cardiovascular diseases, and relevant risk factors were collected.\u003c/p\u003e\n\u003ch3\u003eOperative technique\u003c/h3\u003e\n\u003cp\u003eAll surgical approaches were through a median sternotomy. All operations were performed with the aid of cardiopulmonary bypass (CPB) instituted using atrial drainage and cannulation of the distal ascending aorta, or right axillary artery if proximal arch involved, for arterial return. To prevent potential retrograde thromboembolic events, we decided to avoid femoral cannulation. Axillary cannulations were performed by direct insertion of arterial cannula instead of sewing a side arm-graft. Circulatory arrest (CA) was instituted in 4 patients just after lowering the vesical temperature to 22\u0026ndash;26\u0026deg;C. The cerebral protection was maintained by moderate hypothermia with anterograde cerebral perfusion (ACP) during CA. Near-infrared spectroscopy (NIRS) for Intraoperative cerebral monitoring, and simultaneous radial artery pressure measurement of both arm were mandatory. In 4 cases necessitating selective ACP, innominate and left subclavian artery were clamped and then graft to aorta anastomosis was openly performed after excising diseased arch segment. Antegrade or retrograde cold blood cardioplegia (or both, if extensively diseased coronary arteries present) was used for myocardial protection.\u003c/p\u003e \u003cp\u003eComposite conduits were implanted using the same technique throughout the study period: excision of the native valve and preparation of the coronary buttons were followed by implantation of composite graft to the annulus using interrupted U sutures of pledgeted 2\u0026thinsp;\u0026minus;\u0026thinsp;0 polyester. A running suture of 3\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene was used to stitch the remnants of aorta surrounding the native annulus to the sewing ring of the graft to provide better hemostasis. First the left and then the right coronary button anastomoses were performed using 5\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene. Distal end of the graft was sewn to the distal aorta with externally lied teflon strip over the anastomosis line. Before aortic clamp removal, we connected a vacuum suction line to the aortic vent while applying fibrin glue to the anastomosis line. The patients were weaned from CPB after rewarming and air evacuation.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Follow-up\u003c/h2\u003e \u003cp\u003eBefore leaving the hospital, all patients had to undergo a clinical evaluation with routine laboratory and transthoracic echocardiogram. The patients were scheduled to engage follow-up visits at different intervals. These intervals included 1st month, 3rd months, 6th months, and at the end of 1st year. The total follow-up time of patients is 1963 patients/year. Long-term anticoagulation was maintained with a target international normalized ratio (INR) of 2-2.5. They are specifically informed about the need to receive computed tomography (CT) angiography within the first year after the procedure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy endpoints\u003c/h3\u003e\n\u003cp\u003e The study endpoints are: (1) mid- and long-term mortality; (2) mid- and long-term morbidity; and (3) in-hospital freedom from all-cause major adverse events as defined according to the established guidelines. During long-term follow-up, it was also recorded whether patients developed a documented noncardiac co-morbidity that resulted in death.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;1 SD or median; categorical variables are reported as a percentage; a commercial statistical software package (SPSS for Windows, version 25.0, SPSS Inc, Chicago, Ill) was used for data analysis. Analysis of the actuarial survival curve was performed by use of the Kaplan-Meier estimation for freedom from death and freedom from major complications.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative data\u003c/h2\u003e \u003cp\u003eA total of 48 patients underwent a modified Bentall procedure. The baseline characteristics of these patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were 40 males (84%), with a mean age 61.64\u0026plusmn;5.85. Preoperatively, 7 patients were in New York Heart Association (NYHA) functional class II, 29 in Class III, and in Class IV were 12 patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative Characteristics BMI: body mass index, AR: aortic regurgitation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.64\u0026plusmn;5.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender(M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40(83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA functional class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(14.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(60.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eLeft Ventricular Ejection Fraction\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;60%\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e16(33.3%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBetween 59% \u0026minus;\u0026thinsp;40%\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e27(56.2%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;39%\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e5(10.4%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25(52.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(54.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(6.25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20(41.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObesity (BMI\u0026gt;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic lung disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(31.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(10.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(4.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAortic valve disease\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModerate AR\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e10(20.8%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSevere AR\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e32(66.7%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStenosis\u0026thinsp;+\u0026thinsp;Regurgitation\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e6(12.5)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending Aorta(cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63,6\u0026plusmn;8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOperative and Early results\u003c/h2\u003e \u003cp\u003eThere was one hospital death due postoperatively diagnosed von Willebrand disease and excessive hemorrhage. The bleeding resulted in multi-organ failure and he was lost at 6th day after the operation (2.1%). Carbomedics Carbo-seal Valsalva\u0026trade; composite grafts were used in all patients (100%). The valve sizes were 23 mm (4 patients; 8.33%), 25 mm (30 patients; 62.5%), 27 mm (12 patients; 25%), and 29 mm (2 patients; 4,16%). A standard MBP was performed in the vast majority of patients (n\u0026thinsp;=\u0026thinsp;44; 91,6%) while 4 patients (8,4%) had additional hemiarch replacement. Concomitant procedures were performed in 7 patients (14,58%) as Mitral valve repair in 2 patients (4,16%) and coronary artery bypass grafting in 5 patients (14,58%). Except 6 cases (12.5%) necessitating axillary site for diseased arch, arterial cannulation was mostly through the ascending aorta. We conducted deep circulatory arrest with antegrade SCP in only four patients. The mean CPB time was 168.45\u0026thinsp;\u0026plusmn;\u0026thinsp;37.36 min, and the mean aortic cross-clamp time was 128.64\u0026thinsp;\u0026plusmn;\u0026thinsp;14.36 min. Mean of bleeding was 750 ml (min. 450 ml, max. 5600 ml). Surgical re-exploration for bleeding was needed in only one patient (preoperatively undiagnosed von Willenbrand patient). Further, perioperative characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. No patients experienced respiratory complications requiring prolonged ventilation, endocarditis, or pericardial effusion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross-clamp time(min.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u0026plusmn;14\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerfusion time(min.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151\u0026plusmn;14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal circulatory arrest(min.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026plusmn;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTotal circulatory arrest(n)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e4(8.33%)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBleeding (ml)\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e750(min. 450 ml, max. 5600 ml)-included Von Willenbrand patient\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation for bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital Death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause of hospital death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVon Willebrand disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2\u0026plusmn;2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay(days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0\u0026plusmn;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral valve repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(4.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery bypass surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(10.42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProsthesis size (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8.33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLate results\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMortality\u003c/h2\u003e \u003cp\u003eThe summary of postoperative mortality can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There were 4 deaths, with an overall mortality of 8.3%. Three deaths were observed in late follow-up. The causes of death (6.38%) was chronic heart failure, cerebral hemorrhage and pulmonary complications. The aortic valve-conduit did not directly cause mortality. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the results of the Kaplan-Meier analysis regarding freedom from all-causes death at 5 and 12 years were 97% and 93%, respectively (CI 95%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEarly and late results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day death cause\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVon Willebrand disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate death causes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor anticoagulant-related events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebellar ischemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMorbidity\u003c/h2\u003e \u003cp\u003ePostoperative complications are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. One patient, who underwent concomitant MBP surgery and mitral valve repair, had symptoms of cerebellar ischemia on the 14th day. Symptoms resolved five days later with medical treatment. Four patients suffered different types of bleeding due to high INR level: two had a cerebral haemorrhage, one experienced gastrointestinal haemorrhage, and another had hemoptysis. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the results of the Kaplan-Meier analysis regarding freedom from all causes of late complications during the follow-up period. The Kaplan-Meier curves showed event-free survival at 5 and 12 years 98% and 82%, respectively (CI 95%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main finding of this study is that aortic root replacement with Carbomedics Carbo-seal Valsalva\u0026trade; graft for dilated aortic root in a low volume center provides an acceptable clinical outcome with low mid- and long-term complication rates. Although more than 20% of them had undergone an additional intervention (hemiarch, mitral and coronary surgery), patients at sixties had achieved 93% of survival rate throughout following 12 year. Untreated aortic root dilatation may culminate in life-threatening acute aortic dissection or rupture [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Bentall inclusion technique with various modification, became the standard practice for surgical treatment of anuloaortic ectasia for many years. Bleeding, perioperative myocardial infarction, right ventricular dysfunction, heart rhythm, low cardiac output, heart attack, stroke, infection, cute renal failure, prolonged mechanical ventilation, new pseudoaneurysm, tromboembolism or dissection of the aorta are still cause of mortalty and the morbidity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Surgical modifications and use of newly designed grafts are being performed and published worldwide to manage these complications [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As an additional technical modification, just before removing aortic clamp we connected the vacuum line to venting cannula to prevent oozing blood while applying a fibrin sealant around anastomosis line.\u003c/p\u003e \u003cp\u003eSince it has been performed for decades even in small clinics, The technical details of the Bentall procedure are well deliniated (sequential suturing of valve ring, left coronary button, right coronary button and distal aortic anastomosis) and achieving individual expertise is comperably easier than valve spearing root procedure. The Carbomedics Carbo-seal ValsalvaTM composite graft has has a vertical oriented pleats at valsalva portion alloving accurate targeting and easy anastomosis of the coronary buttons [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Besides, the theoretical benefits of using the Valsalva graft includes: less mobilization and dissection of coronary sin\u0026uuml;s to implant valsalva graft, offering less tension and less probability of kinking or rotation comprimising coronary flow. It also creates eddy current in aortic root is favoring coronary supply, promoting valve closure and decreasing thrombotic affinity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. We believe that these factors have contributed to keep early postoperative complications at acceptable range in our narrow patient population. 2.1% mortality (due to postoperative diagnosis of vWD and eventual death) and one thrombotic cerebral event is comperable with recent reports including valve sparing and biograft surgeries. The evidence presented is concordant to the inferences reported in the guideline by American Heart Association and American College of Cardiology in 2022[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrent guidelines and large scale studies recommend valve-sparing surgery and bioprosthetic conduits for selected subgroup to avoid thromboembolic complications caused by mechanical valves [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Bioprostheses are quite expensive, and also valve-sparing surgery carries appearent risk early failure especialy during learning curve. Moreover, the considerable amount late failure necessitating the valve-in-valve reintervention increases the cost of wellbeing after the root repair for a low flow center. The patients requiring aortic root surgery in the developing countries are getting older and that is concordant to countries of the West. However, the resources for health financing does not show parallel expanse. We actually may have hesitated to do valve-sparing surgery, because the learning curve for AVS surgery is steep and unforgiving of even small technical errors, it is challenging to master the art of AVS surgery and maintain successful and durable outcomes in low-volume centers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The overall late mortality rate in our study is 6.25%. We found that none of the patients in this series required further treatment for cardiac issues such as endocarditis or valve dysfunctions. Based on our experience, we have found that the MBP can be conducted with minimal risks and complications. This surgical procedure has a low rate of both mortality and morbidity, meaning that the chances of death or post-operative complications are significantly reduced.\u003c/p\u003e \u003cp\u003eThe modified Bentall procedure is likely to remain the standard approach for this disease, despite valve-sparing procedures having gained increasing popularity to correct aortic regurgitation caused by aortic root pathology[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Regardless of underlying disease the Bentall may also be the most appropriate choice in low flow clinics. Experiences suggest that the early appearance of aortic insufficiency after a valve-sparing operation leads rapidly to progressive hemodynamic deterioration, making it a riskier alternative than a Bentall procedure in the presence of severe preoperative myocardial dysfunction. Patients with moderate or severe preoperative aortic insufficiency may experience less favorable outcomes after valve-sparing surgery compared to those with mild aortic regurgitation[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe use of composite graft with mechanic valve obligates anticoagulation. Even though closer follow-up of those decent population is possible in a small country, we still experienced six events that were directly related to warfarin. The introduction of home testing of coagulation status offers a new opportunity for improved follow-up of patients undergoing mechanical valve replacement. Furthermore, Schmidtke and coworkers demonstrated that self-management of anticoagulation leads to a superior quality of life after mechanical valve replacement compared with conventional physician-monitored anticoagulation[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWhen analyzing the findings of this study, it is important to consider some limitations. Firstly, our study is conducted retrospectively. In addition, it is important to note that the study conducted was limited to only one team, without the control group. As a result, it was limited by the relatively small number of patients included. Despite these limitations, our study provides long-term outcomes in patients who underwent aortic root replacement with Carbomedics Carbo-seal Valsalva\u0026trade; composite grafts.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the study shows that the rates of mortality and morbidity after MBP with Carbomedics Carbo-seal Valsalva\u0026trade; composite grafts over a long period were similar to those in other research studies. Easly established classic surgery with low cost may still continue to be in use for elderly yielding comperable outcomes in both the short term and the long term. However, anticoagulation-related complications continue to pose a significant challenge that needs to be addressed effectively. It is crucial to prevent and manage these complications carefully to ensure patient safety.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRC:\u0026nbsp;Conception, Design of the work, Acquisition, analysis, Interpretation of data, Writing\u003c/p\u003e\n\u003cp\u003eDK: Writing-review and editing\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBentall HH, de Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23:338\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCabrol C, Pavie A, Gandjbakhch I, Villemont JP, Guiraudon G, Lauglin L, et al. Complete re-placement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg. 1981;81:309\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKouchoukos NT, Wareing TH, Murphy SF, Perillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg. 1991;214:308\u0026ndash;18. discussion 318\u0026ndash;320.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies RR, Goldstein LJ, Coady MA, Tittle SL, Rizzo JA, Kopf GF, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. AnnThorac Surg. 2002;73:17\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JB, Spotnitz M, Lindsay ME, MacGillivray TE, Isselbacher EM. Sundt 3rd TM: Risk of aortic dissection in the moderately dilated ascending aorta. J Am Coll Cardiol. 2016;68:1209\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHagl C, Strauch JT, Spielvogel D, Galla JD, Lansmanc SL, Squitieri R, et al. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Ann Thorac Surg. 2003;76:698\u0026ndash;703. discussion 703.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePratali S, Milano A, Codecasa R, De Carlo M, Borzoni G, Bortolotti U. Improving hemostasis during replacement of the ascending aorta and aortic valve with a composite graft. Tex Heart Inst J. 2000;27(03):246\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoo HC, Chang BC, Youn YN, Youn YN, Yoo KJ, Lee S. Clinical experience with the Bentall procedure: 28 years. Yonsei Med J. 2012;53(5):915\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMookhoek A, Korteland NM, Arabkhani B, Di Centa I, Lansac E, Bekkers, et al. Bentall procedure: a systematic review and meta-analysis. Ann Thorac Surg. 2016;101(5):1684\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYakut C. A new modified Bentall procedure: the flanged technique. Ann Thorac Surg. 2001;71:2050\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Paulis R, Salica A, Pisani G, Morbiducci U, Weltert L, Maselli D. Hemodynamics of aortic valve and root: implications for surgery. Ann Cardiothorac Surg. 2013;2:40\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLechiancole A, Vendramin I, Sponga S, Piani D, Benedetti G, Meneguzzi M, et al. Bentall procedure with the CarboSeal\u003csup\u003e\u0026trade;\u003c/sup\u003e and CarboSeal Valsalva\u003csup\u003e\u0026trade;\u003c/sup\u003e composite conduits: long-term outcomes. Interact CardioVasc Thorac Surg. 2021;33:93\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBortolotti U. Avoiding Bleeding in the Modified Bentall Procedure. Aorta(Stamford). 2021;9(2):92\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Kerchove L, Boodhwani M, Glineur D, Vandyck M, Vanoverschelde JL, Noihomme P, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavid TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg. 2017;153:232\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuciani GB, Casali G, Tomezzoli A, Mazzucco A. Recurrence of aortic insufficiency after aortic root remodeling with valve preservation. Ann Thorac Surg. 1999;67:1849\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidtke C, Huppe M, Berndt S, Notzold A, Sievers HH. Quality of life after aortic valve replacement. Self- management or conventional anticoagulation therapy after mechanical valve replacement plus pulmonary autograft. Z Kardiol. 2001;90:860\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Modified Bentall procedure, aortic root replacement, aortic surgery","lastPublishedDoi":"10.21203/rs.3.rs-6671320/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6671320/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe modified Bentall procedure (MBP) employing the Carbomedics Carbo-seal Valsalva\u0026trade; graft may be used to treat patients with annuloaortic ectasia. In this study we focused on patients who underwent MBP to treat annuloaortic ectasia. Our goal was to review the outcomes of these surgeries over a long period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom 2012 to 2024 48 consecutive patients with annuloaortic ectasia underwent aortic root replacement with Carbomedics Carbo-seal Valsalva\u0026trade; graft. Concomitant cardiac procedures were performed in 7 patients (MBP+Mitral valve annuloplasty, 2 patients and MBP+Coronary artery bypass grafting, 5 patients). Mean Cardiopulmonary bypass and aortic clamp time for were 151\u0026plusmn;37 and 128\u0026plusmn;14 minutes, respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe operative mortality was 2.1% (n\u0026thinsp;=\u0026thinsp;1). Late causes of death were chronic heart failure (1 patient, 2.1%), cerebral haemorrhage (1 patient, 2.1%) and pulmonary complications (1 patient, 2.1%). And major late complications included cerebral hemorrhage in 2 patients (4.2%), cerebellar ischemia in 1 patient (2.1%) and gastrointestinal hemorrhage in 2 patient (4.2%). Kaplan-Meier estimated survival rates for 5 and 10 years were 96.22% and 95.20% respectively. The Kaplan-Meier curves showed event-free survival at 5 and 12 years 98% and 82%, respectively (CI 95%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMBP operations for annuloaortic ectasia, with Carbomedics Carbo-seal Valsalva\u0026trade; graft, can be performed with a low mid- and long-term mortality and morbidity in low-volume centers.\u003c/p\u003e","manuscriptTitle":"Replacement of the ascending aorta and aortic valve for Annuloaortic ectasia with Carbomedics Carbo-seal ValsalvaTM graft: mid- to long-term results","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 16:14:37","doi":"10.21203/rs.3.rs-6671320/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"de963e9c-ad74-4819-b899-490006fde332","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-25T18:23:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 16:14:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6671320","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6671320","identity":"rs-6671320","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}