Original Article Primary or secondary Bentall-De Bono procedure: are the outcomes worse? Ameya Kaskar , Deepak V Bohra, Rahul Rao K, Varun Shetty and Devi Shetty Abstract Background: The aim of this study was to compare the outcomes of a primary and secondary Bentall-De Bono procedure. Methods: From 2008 to 2015 (8-year period), 308 patients underwent a Bentall-De Bono procedure in our institute. The mean age was 43  13 years and 80% were men. Twenty-eight patients had prior cardiac surgery through a median sternotomy (group 1) and 280 underwent a primary Bentall-De Bono procedure (group 2). Various preoperative and perioperative parameters were analyzed before and after propensity-score matching. Results: Before propensity-score matching, patients undergoing a secondary Bentall-De Bono procedure had a worse preoperative profile, as indicated by a higher EuroSCORE II (p < 0.0001), with hospital mortality in group 1 of 14% (4/28) and 5% (14/280) in group 2 (p ¼ 0.069). After propensity-score matching, there was no significant difference in EuroSCORE II (p ¼ 0.922) or hospital mortality (p ¼ 0.729). After adjusting for the different variables, repeat sternot- omy could not be identified as an independent predictor of postoperative mortality or morbidity. Survival at the end of 1 and 5 years in both groups showed no significant differences before or after propensity-score matching (p ¼ 0.328 and p ¼ 0.356, respectively). In Cox multivariable regression analysis, reoperation was not identified as an independent factor for survival before (p ¼ 0.559) or after propensity-score matching (p ¼ 0.365). Conclusion: A secondary Bentall-De Bono procedure can be performed with acceptable mortality and morbidity, and with midterm survival rates comparable to those of a primary Bentall-De Bono procedure. Keywords Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Postoperative complications, Reoperation, Treatment outcome, Vascular surgical procedures. Introduction The Bentall-De Bono procedure for aortic root replace- ment is the gold standard for treating aortic root pathology. 1 A secondary Bentall-De Bono procedure is being increasingly performed, but is considered to be a clinical challenge due to high mortality rates of 3% to 17.9% in different studies. 2–8 The increasing frequency of a secondary Bentall-De Bono procedure is due to the increasing number of operations being performed on the aortic root, ascending aorta, and aortic arch, and the greater use of bioprosthetic con- duits, homografts, and autografts, which are bound to deteriorate, along with an increase in reparative aortic root reconstructions, 9 such as valve-sparing aortic root replacement that may require repeat replacement of the aortic root in the future. 2,4,10,11 Although a primary Bentall-De Bono procedure yields excellent results, as a reoperation, it has traditionally been thought to be associated with high mortality rates due to difficulty in sternal reentry and coronary artery mobilization and reimplantation. The surgical outcomes have improved in recent decades due to various modifications to the original procedure and technological improvements such as the development of new aortic root substitutes, Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bangalore, India Corresponding author: Ameya Kaskar, Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Narayana Health, #258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore 560099, Karnataka, India. Email: ameyak007@rediffmail.com Asian Cardiovascular & Thoracic Annals 0(0) 1–7 ! The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0218492319832775 journals.sagepub.com/home/aan