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We read with great interest the article by Koshiyama et al. [1] regarding reinforcement of the proximal anastomosis during composite graft replacement of the aortic root, using one of the modifications of the Bentall and DeBono technique [2]. Modified Bentall procedures have many beneficial effects such as prevention of excessive bleeding and development of false aneurysm, avoidance of the kinking of coronary arteries, as well as reduced tension on ‘button’ coronary anastomoses. However, a major weakness in the composite graft replacement of the ascending aorta is haemostasis at the proximal suture line. A refined, flanged Bentall technique using Vasalva tube graft reported by Koshiyama et al. [1] is similar to the flanged technique reported by Yakut [3], previously. The Valsalva sinus portion of the graft is resected, leaving 10 mm in length as the flange and is everted outwards using Koshiyama’s technique [1], whether a segment (several millimetres in a length) of the proximal end of vascular graft is everted outwards to form the flange of the graft using Yakut’s technique [3]. The polypropylene running suture (3–0 or 4–0) is used to anastomose the cuff of the prosthetic valve to the bottom border of the chosen conduit. Subsequently, the flange is returned to its original position. In both techniques, the homemade composite conduit is seated on the aortic annulus, using continuous 3–0 polypropylene suture [3], or everting pledgeted 2–0 polyester sutures [1], which are passed through the flange below the sewing cuff of the prosthetic valve. Koshiyama et al. [1] stated that using 3–0 polyprolene suture to sew the flange and the margin of the residual proximal aortic wall enabled them to wrap tightly all of the proximal anastomosis line. However, as it can be easily seen on figure 1D of their manuscript [1], only the pledgets of the tied everting pledgeted 2–0 polyester sutures are covered, while the knots of these sutures are still ‘naked’, outside, on the flange, between the flange and prosthetic tube, thus leaving pinholes of the everting mattress sutures as the potential sites of bleeding. On the contrary, Chen et al. [4] modified the composite graft by adding a short skirt (which was made of a part of the distal end of the prosthetic tube) to a standard composite graft root. After the proximal end of the modified composite conduit was secured in the aortic annulus, the short skirt was sewn to the remaining native proximal aortic wall to really wrap all of the proximal anastomosis line. However, we have to point out that Copeland et al. [5] reported an elegant, easily reproducible, and efficient technique to reduce bleeding from the proximal anastomosis after the Bentall procedure. After the composite conduit is seated into the aortic annulus and the sutures are tied, an additional 3–0 polypropylene suture is used to sew the cut edge of the proximal aortic wall and the prosthetic sewing cuff or the prosthetic tube, thus reinforcing and really completely covering all of the proximal anastomosis line.

A refined flanged Bentall technique using Valsalva tube graft: does it really wrap all of the proximal anastomosis line?