A case study of Bentall procedure + mitral valve replacement (MVR)

Roshini1*, Hemaltha2, Sri Preethi3, Jaya Menon4

1Staff Nurse, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

2Assistant Nursing Superintendent , Kauvery Hospital, Heart city, Trichy, Tamil Nadu

3Nurse Educator , Kauvery Hospital, Heart city, Trichy, Tamil Nadu

4Nursing Superintendent, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

*Correspondence

Abstract

The Bentall procedure combined with Mitral Valve Replacement (MVR) is a major cardiac surgical procedure performed in patients with complex aortic root and mitral valve pathology. The Bentall procedure involves replacement of the aortic valve, aortic root, and ascending aorta with a composite graft, with reimplantation of the coronary arteries. MVR involves replacing a diseased mitral valve with a mechanical or bioprosthetic valve. This case study describes the clinical presentation, diagnosis, medical and surgical management, and nursing care of a patient undergoing Bentall procedure with MVR. Appropriate preoperative assessment, cardiopulmonary bypass management, postoperative hemodynamic monitoring, anticoagulation, respiratory care, infection prevention, and patient education are essential for successful recovery.

Keywords: Mitral valve replacement; Bentall procedure with MVR, Coronary arteries

Introduction

The aortic root and mitral valve can be affected by conditions such as aneurysm, aortic regurgitation, mitral stenosis, mitral regurgitation, connective-tissue disorders, rheumatic heart disease, and infective endocarditis. When significant disease affects both the aortic root and mitral valve, combined surgical treatment may be required. The Bentall procedure was developed to treat diseases involving the aortic root and ascending aorta together with the aortic valve. It replaces the diseased aortic root, ascending aorta, and aortic valve using a composite graft and reconnects the coronary arteries to the graft. MVR replaces a severely diseased mitral valve when repair is not suitable. Because this is a complex cardiac operation, meticulous perioperative and postoperative nursing care is required.

Case Presentation

The patient presented a history of progressive cardiac symptoms. The patient had a known history of valvular heart disease with associated aortic root/ascending aortic pathology. There was a history of progressive exertional limitations and symptoms suggestive of worsening cardiac function. The patient underwent clinical examination, electrocardiography, echocardiography, laboratory investigations, and other imaging studies as indicated. Based on the findings, surgical intervention with Bentall procedure and mitral valve replacement was planned.

Present complaints

  • Breathlessness, particularly on exertion
  • Easy fatigability
  • Reduced exercise tolerance
  • Palpitations
  • Occasional chest discomfort
  • Symptoms of fluid retention such as pedal edema, if present

Investigations

Lab Investigations

Investigations Value
Hemoglobin13.4
PCV38.4
Total RBC Count4.80
MCV80.0
MCH27.9
WBC5520
PT(Test)12.4
PT(Control)10.7
INR1.16
Bleeding time3 Mins
Clotting Time 7 Mins

Other investigations

  • 2D echocardiography with Doppler
  • CT angiography of the aorta: Helps evaluate aortic root and ascending aortic aneurysms or dissection.

Coronary angiogram report

Impression

Procedure: Right radial angiogram

Catheter: 5F TIG

Left Main Coronary Artery Normal, Bifurcates into LAD and LCX.
Left Anterior Descending Artery Type - III LAD, Normal.
Left Circumflex Artery Non - Dominant, Normal.
Right Coronary Artery Dominant, Normal.
Diagnosis Normal Epicardial Coronaries
Recommendations & Plan DVR

ECHO

Impression

  • S/P Mitral Valve Repair
  • Mild to Moderate MR (ECCENTRIC JET)
  • Good LV Function
  • Aortic Root Dilated
  • Moderate AR
  • Mild TR/Mild PAH

Chest X -ray

ECG

Management

Medical Management

Preoperative management

  • Control of blood pressure and heart rate as prescribed.
  • Diuretics for congestion or fluid overload when indicated.
  • Management of heart failure symptoms.
  • Correction of electrolyte abnormalities.
  • Optimization of anemia and nutritional status.
  • Antibiotic prophylaxis according to institutional protocol.
  • Preoperative anticoagulant/antiplatelet management according to surgical instructions.

Postoperative management

  • Analgesics for pain control.
  • Inotropes/vasopressors such as noradrenaline, adrenaline, dobutamine, or milrinone when clinically indicated.
  • Diuretics for fluid management.
  • Electrolyte replacement according to laboratory values.
  • Antibiotics when indicated.
  • Anticoagulation for a mechanical prosthetic valve according to the prescribed regimen.
  • Antiplatelet therapy when indicated.

Surgical Management

The patient undergoes median sternotomy followed by establishment of cardiopulmonary bypass.

Bentall procedure

  • Median sternotomy is performed.
  • Cardiopulmonary bypass is established.
  • The diseased aortic valve and aortic root/ascending aorta are excised.
  • A composite valved conduit is implanted.
  • The coronary arteries are reimplanted into the graft.
  • The distal graft is connected to the ascending aorta.
  • The heart is de-aired and weaned from cardiopulmonary bypass.

Mitral Valve Replacement

  • The mitral valve is exposed through the appropriate surgical approach.
  • Diseased mitral valve tissue is removed while preserving suitable sub valvular structures where possible.
  • A prosthetic mechanical or bioprosthetic valve is implanted.
  • Valve function is assessed.
  • The heart is de-aired and the patient is weaned from CPB after adequate hemodynamic assessment.

Intraoperative transesophageal echocardiography may be used to assess prosthetic valve function, ventricular function, residual regurgitation, and other surgical results.

Nursing Management

Preoperative nursing care

  • Assess vital signs and cardiovascular status.
  • Monitor symptoms of heart failure.
  • Assess respiratory status and oxygen saturation.
  • Explain the surgical procedure and postoperative expectations.
  • Provide psychological support and reduce anxiety.
  • Ensure required investigations are completed.
  • Maintain NPO status as ordered.
  • Prepare the patient according to cardiac surgery protocol.
  • Verify blood availability and documentation.
  • Administer prescribed medications.

Immediate postoperative nursing care

  • Maintain airways and assess ventilator parameters.
  • Monitor SpO₂, respiratory rate, ABG, and chest movements.
  • Continuous ECG monitoring.
  • Monitor heart rate and rhythm for AF, VT, bradycardia, or other arrhythmias.
  • Monitor invasive blood pressure and central venous pressure as prescribed.
  • Assess peripheral perfusion and urine output.
  • Monitor chest-tube drainage and report excessive bleeding.
  • Maintain strict intake and output.
  • Monitor temperature and prevent hypothermia.
  • Monitor hemoglobin, platelet count, coagulation profile, electrolytes, lactate, and renal function.
  • Observe for signs of low cardiac output.
  • Administer inotropes and vasopressors according to prescribed infusion protocols.
  • Provide adequate analgesia.
  • Maintain aseptic technique for invasive lines and surgical wounds.

 

Anticoagulation care

Patients with a mechanical mitral or aortic prosthesis generally require long-term anticoagulation. The nurse should monitor:

  • Administer anticoagulants as prescribed.
  • Monitor PT/INR according to the prescribed schedule.
  • Observe for bleeding or thromboembolic complications.
  • Educate the patient about medication adherence.
  • Teach the patient to report unusual bleeding, black stools, severe headache, or neurological symptoms.

Respiratory care

  • Suction when indicated using aseptic technique.
  • Encourage deep breathing and coughing after extubating.
  • Use incentive spirometry according to protocol.
  • Encourage early mobilization when hemodynamically stable.
  • Monitor for atelectasis and pulmonary infection.

Wound and infection prevention

  • Assess sternotomy and drain sites.
  • Maintain sterile/aseptic technique.
  • Monitor temperature and WBC count.
  • Observe for redness, swelling, discharge, or wound dehiscence.

Fluid and electrolyte management

  • Strict intake and output monitoring.
  • Monitor urine output.
  • Assess for edema and pulmonary congestion.
  • Monitor sodium, potassium, magnesium, calcium, and renal function.
  • Administer replacement therapy as ordered.

Discussion

Bentall procedure combined with MVR is a complex cardiac surgery requiring careful coordination between the cardiac surgeon, anesthesiologist, perfusionist, intensivist, and nursing team. The major goals are correction of aortic root pathology and restoration of appropriate mitral valve function. The postoperative period carries risks including bleeding, cardiac tamponade, low cardiac output syndrome, arrhythmias, respiratory complications, acute kidney injury, infection, neurological complications, and prosthetic valve-related thromboembolism. Early recognition of abnormal trends through continuous monitoring is therefore essential.

Outcome

Following Bentall procedure and MVR, the patient was monitored in the CTICU. Hemodynamic parameters, cardiac rhythm, respiratory status, chest-tube drainage, urine output, laboratory investigations, and neurological status were closely monitored. With appropriate postoperative management, the patient showed progressive clinical improvement, was weaned from ventilatory and circulatory support as tolerated, and gradually mobilized. The surgical wound remained under observation for infection and healing. Before discharge, education regarding medications, anticoagulation if applicable, wound care, activity progression, follow-up, and warning signs was provided.

Conclusion

Bentall procedure with MVR is a major cardiac surgical intervention for patients with combined aortic root/ascending aortic and mitral valve disease. Successful recovery depends on accurate diagnosis, appropriate surgical treatment, vigilant CTICU monitoring, and comprehensive nursing care. Early identification of bleeding, arrhythmias, low cardiac output, respiratory problems, renal dysfunction, infection, and anticoagulation-related complications can significantly improve patient outcomes. Patient and family education is essential for long-term management, particularly when a mechanical prosthetic valve is used.

References:

  1. Otto, C. M., & Nishimura, R. A. (2020). 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation, 143(5), e72–e227.
  2. Isselbacher, E. M., Preventza, O., Hamilton Black, J., III, Augoustides, J. G. T., Beck, A. W., Bolen, M. A., Braverman, A. C., Bray, B. E., Brown-Zimmerman, M. M., Chen, E. P., Collins, T. J., DeAnda, A., III, Fanola, C. L., Girardi, L. N., Hicks, C. W., Hui, D. S., Kalahasti, V., Kim, K. M., Milewicz, D. M., … Sundt, T. M., III. (2022). 2022 ACC/AHA guideline for the diagnosis and management of aortic disease. Circulation, 146(24), e334–e482.
  3. Vahanian, A., Beyersdorf, F., Praz, F., Milojevic, M., Baldus, S., Bauersachs, J., Capodanno, D., Conradi, L., De Bonis, M., De Paulis, R., Delgado, V., Freemantle, N., Haugaa, K. H., Jeppsson, A., Jüni, P., Pierard, L., Prendergast, B. D., Sádaba, J. R., Tribouilloy, C., & Wojakowski, W. (2022). 2021 ESC/EACTS guidelines for the management of valvular heart disease. European Heart Journal, 43(7), 561–632.
  4. Otto, C. M., Nishimura, R. A., Bonow, R. O., Carabello, B. A., Erwin, J. P., III, Gentile, F., Jneid, H., Krieger, E. V., Mack, M., McLeod, C., O’Gara, P. T., Rigolin, V. H., Sundt, T. M., III, & Thompson, A. (2021). 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary. Journal of the American College of Cardiology, 77(4), 450–500.

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment