A Bentall procedure is an open-heart surgery that replaces the aortic valve, the aortic root (the first section of the aorta where it connects to the heart), and the ascending aorta all at once, using a single combined graft with a valve already sewn into it. The coronary arteries, which supply blood to the heart muscle itself, are then reattached to the new graft. First performed in 1968 by Hugh Bentall and Antony De Bono, it remains the standard surgical approach for people whose aortic root has become dangerously enlarged or diseased.
Why the Procedure Is Needed
The most common reason for a Bentall procedure is an aortic root aneurysm, where the base of the aorta balloons outward and weakens. As the aneurysm grows, so does the risk that the aorta will tear (dissect) or rupture. An aortic root wider than 6 centimeters carries a fourfold increase in the risk of rupture or dissection. Surgery is typically recommended before that point, usually when the diameter reaches about 5.0 centimeters.
People with Marfan syndrome, a connective tissue disorder that weakens the aortic wall, are especially likely to need this surgery. For these patients, surgery may be recommended even before the 5.0 cm threshold if the aorta is growing rapidly (more than 1 cm per year), if there’s a family history of aortic dissection at smaller sizes, or if the aortic valve is already leaking significantly. Other conditions that can lead to a Bentall procedure include bicuspid aortic valve disease, aortic dissection, and other connective tissue disorders that affect the aorta.
What Happens During Surgery
The procedure is performed through an incision in the chest while the patient is on a heart-lung bypass machine. The surgeon removes the damaged section of the aorta and the aortic valve, then replaces both with a composite graft: a synthetic tube made of woven polyester with a prosthetic valve already attached inside it.
The trickiest part is reconnecting the coronary arteries. These two small arteries branch off the very base of the aorta, and they must be carefully detached and sewn onto the new graft so blood can continue flowing to the heart muscle. In the original 1968 technique, the coronary arteries were stitched directly to openings cut in the graft. This led to high rates of bleeding and a serious complication called pseudoaneurysm, where the connection point bulges outward.
Today, virtually all surgeons use a modified “button” technique. Instead of stitching the artery openings directly, the surgeon cuts out small circular patches of the original aortic wall surrounding each coronary artery, creating button-shaped tissue cuffs. These buttons are then sewn onto corresponding holes in the graft, creating a stronger, more secure connection. This modification dramatically reduced complications like coronary detachment and the need for reoperation.
Mechanical vs. Biological Valves
One of the most important decisions before a Bentall procedure is which type of valve goes into the graft. The two options, mechanical and biological, involve a genuine trade-off.
Mechanical valves are extremely durable and rarely need to be replaced. The catch is that they require lifelong blood-thinning medication (typically warfarin) to prevent clots from forming on the valve. That blood thinner increases the risk of bleeding episodes and, in some age groups, stroke. For patients receiving a mechanical aortic valve, blood-thinning levels need to be kept within a specific target range, which means regular blood tests for life.
Biological valves, made from animal tissue, don’t require long-term blood thinners in most cases. But they wear out over time, and the younger you are at surgery, the more likely you’ll eventually need a second operation to replace the valve. Current guidelines generally recommend mechanical valves for patients younger than 50 and biological valves for those older than 70. For people between 50 and 70, either option is reasonable, and the choice comes down to individual priorities: avoiding blood thinners versus avoiding a potential reoperation years later. Large-scale data shows that mechanical valves are associated with lower long-term mortality up to about age 55 for aortic valve replacement, largely because they eliminate the risk of needing a second surgery.
Risks and Survival Rates
For a planned, elective Bentall procedure, the hospital mortality rate is low. In a large series of 597 consecutive patients, elective mortality was 1.4% with mechanical valves and 3.7% with biological valves. Emergency operations, such as those performed during an acute aortic dissection, carry significantly higher risk.
Stroke is the most feared non-fatal complication, occurring in roughly 1.4% to 2% of cases. Other potential complications include bleeding, infection, and, rarely, prosthetic valve endocarditis (infection of the new valve). In one study of elective patients under 65, about 85% were free of any major complication (endocarditis, stroke, bleeding, or blood clots) at five years, and 78% at eight years. The majority of patients in large studies are men (around 85%), and the average age at surgery tends to be in the mid-to-late 40s, reflecting how often this procedure is performed for genetic connective tissue conditions.
Recovery After Surgery
Immediately after the operation, you’ll spend several days in the intensive care unit while the medical team monitors your heart function and manages pain. Most people stay in the hospital for about one week total.
Full recovery takes six to twelve weeks. During the first six weeks, you shouldn’t drive or lift anything heavy. If your job doesn’t involve physical labor, you may be able to return to work after six to eight weeks. Physically demanding jobs will require a longer absence. Your surgical team will schedule follow-up imaging to monitor the graft and, if you received a mechanical valve, will work with you to stabilize your blood-thinning medication at the right level.
Life With a Bentall Graft
The synthetic graft itself doesn’t wear out or degrade. It becomes your permanent aorta. Whether you need long-term medication depends entirely on the valve type. Mechanical valve recipients take warfarin daily and have their blood-clotting levels checked regularly to stay within the therapeutic range. Biological valve recipients generally don’t need long-term blood thinners, though some take low-dose aspirin.
Regardless of valve type, you’ll need periodic imaging (usually echocardiograms or CT scans) to check the graft, the valve function, and the remaining portions of your aorta that weren’t replaced. For people with Marfan syndrome or other connective tissue disorders, this surveillance is especially important because the disease can affect other segments of the aorta over time. Many patients live decades after a Bentall procedure with excellent quality of life, particularly when the surgery is performed electively rather than as an emergency.