Redo Bentall operation for right coronary artery (RCA)

A redo Bentall operation for right coronary artery (RCA) ostial insufficiency represents one of the most technically demanding scenarios in complex aortic root surgery. This condition typically arises from progressive ostial stenosis, kinking, pseudoaneurysm formation, or patch dehiscence following a prior composite valve–graft root replacement, leading to myocardial ischemia, ventricular dysfunction, or refractory angina. Re-entry through a previously operated sternum requires meticulous planning, often with preoperative imaging to define graft position and coronary anatomy, and consideration of peripheral cannulation prior to sternal division to enhance safety. After establishing cardiopulmonary bypass and achieving myocardial protection—frequently challenging due to compromised RCA perfusion—the aortic graft is carefully dissected and opened. The right coronary button is evaluated; if salvageable, it may be revised and reimplanted with careful mobilization to prevent tension or torsion. However, in many redo settings where the ostium is fibrotic or friable, a short interposition graft or coronary artery bypass to the distal RCA using a saphenous vein graft is preferred. Reconstruction must ensure tension-free anastomosis and optimal orientation to avoid recurrent kinking. Hemostasis is particularly critical given dense adhesions and prior suture lines. Successful redo Bentall surgery in this context demands precise surgical judgment, advanced myocardial protection strategies, and thorough intraoperative assessment to restore durable coronary perfusion while minimizing operative morbidity.