Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation

Two hundred fifty-two patients underwent operation for type A aortic dissection at Stanford University Medical Center from 1963 to 1987 and Duke University Medical Center from 1975 to 1988. Sixty-seven percent had an acute type A dissection and 33% had a chronic type A dissection. In addition to repair or replacement of the ascending aorta, 121 patients (48%) required an aortic valve procedure. Valve resuspension was performed in 46 (39 acute type A and 7 chronic type A), with an operative mortality rate of 13% +/- 5% (+/- 70% confidence limits), and aortic valve replacement in 75 (36 acute type A and 39 chronic type A), with an operative mortality rate of 20% +/- 5% (p = not significant versus resuspension). The operative mortality rate for patients requiring only repair or replacement of the ascending aorta was 32% +/- 4%. Indications for valve replacement included coexistent (nonacute) aortic valve disease, Marfan's syndrome, annuloaortic ectasia, and cases in which successful resuspension could not be accomplished. The overall actuarial survival rate for all patients was 59% +/- 3% (+/- 1 standard error of the mean), 40% +/- 4%, and 25% +/- 5% at 5, 10, and 15 years, respectively. Survival rates at these same times for patients with valve resuspension were 67% +/- 8%, 52% +/- 10%, and 26% +/- 19%, respectively; for patients who required aortic valve replacement, these survival rates were 70% +/- 5%, 39% +/- 8%, and 21% +/- 11%; finally, patients who received only an ascending aortic procedure had survival probabilities of 51% +/- 5%, 37% +/- 6%, and 23% +/- 6% (p = not significant versus resuspension versus aortic valve replacement). Multivariate analysis showed advanced age (p less than 0.001), previous cardiac or aortic operation (p less than 0.001), more preoperative dissection complications (p = 0.002), and earlier operative date (p = 0.038) to be the only significant, independent factors that increased the likelihood of early or late death. The type of aortic valve procedure (resuspension versus aortic valve replacement versus none) was not a significant predictor of mortality. Two of 46 patients with valve resuspension required late aortic valve replacement (freedom from aortic valve replacement: 100% and 80% +/- 13% at 5 and 10 years, respectively), as did 4 of 75 patients with initial aortic valve replacement (freedom from repeat aortic valve replacement: 98% +/- 2% and 73% +/- 13%, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)     

Surgical treatment of acute ascending aortic dissection.

Since adopting a policy of immediate operation on patients with acute dissection of the ascending aorta, 42 men and 6 women (ages 18-67 years) have been managed surgically. Thirty-two patients had graft replacement of the ascending aorta and resuspension of the incompetent aortic valve. One of these had a coronary graft. There were five deaths in this group. Eight patients required aortic valve replacement because of a diseased aortic valve as well as grafting of the ascending aorta, with one death. Three patients had resuspension of the aortic valve and primary repair of their dissection without mortality. Two patients were managed successfully with an intraluminal prosthesis and resuspension of the aortic valve. Another patient had successful repair with a valved conduit and reimplantation of the coronaries. Two patients dissected 4 and 6 years after aortic valve replacement and neither survived operative repair. Of the surviving patients, one required dialysis, one a femoral-femoral bypass graft, and one an axillo-femoral bypass graft. One patient required a pacemaker for heart block, and two underwent successful repair of suture line aneurysms, both occurring three years after operation. On the basis of this experience, prompt surgical intervention for acute ascending aortic dissection is the treatment of choice. A variety of techniques are available to repair the dissected aorta. Long-term results for resuspension of the aortic valve in acute ascending aortic dissection have been excellent and emphasize that valve replacement should be reserved for those patients found at operation to have a primary abnormality of the aortic valve.     

Surgery of the ascending aorta: five years'' experience at a regional cardiac centre.

Between 1972 and 1978, 31 patients underwent replacement of the ascending aorta, with or without aortic valve surgery, at the Wessex Regional Cardiac Centre. The commonest indications for operation were aneurysmal dilatation of the ascending aorta causing aortic regurgitation and acute dissection of the ascending aorta. Eleven of the 31 patients had features of Marfan's syndrome. The overall hospital mortality was 19.4%, a figure comparable with those reported in other series; ventricular failure secondary to ischaemia during operation was the commonest cause of death. The long-term symptomatic results were excellent, except in the two patients who underwent resuspension of the aortic valve for aortic regurgiation associated with acute dissections. For aneurysms of the ascending aorta with associated aortic regurgitation, replacement of the valve and ascending aorta with a combined valve prosthesis and synthetic tube graft, with reimplantation of the coronary ostia, is the procedure of choice if the aortic valve ring is diseased. Experience to date indicates that replacement of the ascending aorta and aortic valve with separate prostheses, leaving the coronary ostia undisturbed, is a satisfactory alternative provided the aortic annulus is of suitable size and quality; this is more likely to be the case in dissections than in aneurysmal dilatation of the ascending aorta. Replacement of the ascending aorta may also be indicated in some cases of dilatation of the ascending aorta secondary to aortic valve disease if the aortic wall is unusually thin.     

Long-term effectiveness of operations for ascending aortic dissections

OBJECTIVE: To evaluate long-term effectiveness of a strategy for managing the aortic root and distal aorta according to the pathology in ascending aortic dissection. METHODS: From 1978 to 1995, 208 patients underwent operations for acute (n = 135) and chronic (n = 73) ascending aortic dissection. Surgical strategies included valve resuspension with supracoronary aortic root repair and ascending aortic graft for normal sinuses and valve (n = 135), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 47), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 26). Resection extended into the arch only if the intimal tear originated in or extended to the aortic arch (n = 31). RESULTS: Hospital mortality was 14%. Cardiogenic shock (P =.002) and concomitant coronary artery bypass grafting (P =.001) were associated with increased risk; use of circulatory arrest (P =.0003) decreased risk. Survival was 87%, 68%, and 52% at 30 days, 5 years, and 10 years, respectively. Advanced age, earlier date of operation, composite graft, and arch resection were associated with decreased survival; residual distal dissected aorta was not. Reoperation was required for 5 proximal and 8 distal problems. CONCLUSIONS: In both acute and chronic ascending aortic dissections, (1) circulatory arrest is associated with low early mortality; (2) with normal sinuses and valve, supracoronary repair of the dissected aortic root and valve resuspension is effective long term; and (3) residual distal dissected aorta does not decrease late survival and has a low risk of aneurysmal change and reoperation for at least 10 years.     

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.     

Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection

OBJECTIVE: This study was undertaken to determine significant risk factors for proximal or distal reoperations after surgical correction of acute type A aortic dissection. METHODS: Between 1980 and 2000, a total of 160 consecutive patients (mean age 57.5 +/- 13.3 years, 126 men) underwent surgery for acute type A aortic dissection. Proximal repair was performed by means of ascending aorta replacement with valve resuspension in 130 cases (81.3%), composite graft replacement in 19 cases (11.9%), separate aortic valve and ascending aorta replacement in 7 cases (4.4%), and aortic repair in 1 case (0.6%). Distal repair required arch replacement in 23 cases. Follow-up time averaged 4.51 +/- 5.6 years per patient. RESULTS: Survival estimates after initial operation were 66.1% +/- 3.8%, 57.7% +/- 4.2%, 52.2% +/- 4.6%, and 42.5% +/- 5.8% at 1, 5, 10, and 15 years, respectively. Thirty patients required 37 reoperations at a mean interval of 5.7 +/- 4.5 years after the initial operation. Freedoms from reoperation were 96.9% +/- 1.8%, 74.7% +/- 5.3%, 60.8% +/- 6.8%, and 39.3% +/- 9.1% at 1, 5, 10, and 15 years, respectively. Reoperations included procedures on the proximal aorta (aortic root or valve) in 21 cases and on the distal aorta or its side branches in 19 cases. Cox regression analysis distinguished severe preoperative aortic valve insufficiency as the only significant risk factors for proximal reoperation; younger patient age, more distal extent of dissection, and more recent operative date were found to be significant risk factors for distal reoperation. CONCLUSION: Patients with acute type A aortic dissection who have severe aortic valve insufficiency are at increased risk for proximal reoperation. These patients should benefit from a more aggressive proximal repair at initial operation. Distal extent of aortic resection at initial operation did not significantly influence the risk of distal reoperation.     

Aortic root replacement after operation for the ascending aorta and/or aortic valve

We reviewed ten cases who underwent aortic root replacement after operation for the ascending aorta and/or aortic valve. As initial operation, aortic valve replacement (AVR) was performed in five patients, replacement of the ascending aorta in two, original Bentall operation in two, and entry closure and suspension of the aortic valve in one. At reoperation, three patients were diagnosed as aneurysm of the ascending aorta, two were annulo-aortic ectasia, and one was acute aortic dissection, chronic dissecting aneusym, pseudoaneurysm of the ascending aorta, prosthetic valve endocarditis, and massive aortic regurgitation. Aortic root replacement was performed using mechanical valved composite graft in all cases. One patient who underwent repeat aortic root replacement for prosthetic valve endocarditis was died of septemia and ventricular fibrillation. Five patients had nine complications (two low output syndrome, respiratory failure and cerebral infarction, one gastrointestinal bleeding, septemia and ventricular fibrillation). In conclusion, aortic root replacement after operation for the ascending aorta and/or aortic valve was performed with acceptable morbidity and mortality.     

Effects of ascending aorta replacement on aortic root dilatation.

OBJECTIVE: Because of an increase of aortic root wall stress, prosthetic replacement of the ascending aorta might be a risk factor for the progressive increase of the aortic root dimension. Aim of the present study was to evaluate the aortic root diameter change and the progression of aortic valve regurgitation late after ascending aorta replacement for different ethiology. METHODS: Sixty-three late survivors after supracoronary ascending aortic replacement were evaluated. Forty-one patients were operated on for acute aortic dissecting aneurysm (group I) and 22 for chronic atherosclerotic non-dissecting aneurysm (group II). Aortic root diameter and aortic valve regurgitation were assessed echocardiografically after a mean follow-up of 63+/-31 months and were compared with those early after surgery. RESULTS: Seven patients of group I (17%) needed reoperation for aortic root dilatation or dissection. Twenty-five percent of the patients (15 of group I and 1 of group II) showed at least a 10% increase in aortic root diameter at follow-up (46.8+/-6.1 vs. 38.1+/-6.1mm, P<0.0001). Aortic root diameter increased almost exclusively in patients operated on for acute dissecting aneurysm. A significant worsening of aortic valve insufficiency with time was evident only in patients operated on for acute dissecting aneurysm with an higher incidence in those with progressive root dilatation. CONCLUSIONS: Both the increase of aortic root diameter and the progressive worsening of aortic valve insufficiency seem to justify a more aggressive treatment of the aortic root at the time of surgery for acute aortic dissecting aneurysm but not for chronic atherosclerotic non-dissecting aneurysms.     

Is preservation of the aortic valve different between acute and chronic type A aortic dissections?

OBJECTIVES: In repair of acute type A aortic dissection, the type of proximal repair of the ascending aorta has been of great interest; however, very few reports are available regarding this issue in chronic aortic dissection. The surgical strategies for proximal repair in chronic dissection may not the same as those for acute dissection. We reviewed our 10-year experience of both acute and chronic type A aortic dissections in order to elucidate the validity of valve preservation and the long-term results of aortic regurgitation (AR). METHODS: From 1990 to 1999, 93 patients (55 acute and 38 chronic dissections) underwent operation for type A aortic dissection. Five Marfan patients were included in each group. The degree of AR was evaluated by echocardiography before and after (at hospital discharge and late follow-up) operation. RESULTS: In acute type A aortic dissection (n=55), 16 patients had AR grade II or greater (29%), of whom seven had AR grade III (13%). In 29 patients, dissection was found below the sinotubular junction (STJ) and 14 patients had AR grade II or greater (48%). The aortic valve was replaced in four patients (7%), of whom three had Marfan's syndrome. Only one non-Marfan patient required aortic valve replacement because of valve stenosis. In those whose aortic valve was preserved (n=51), three patients still had AR grade II at hospital discharge, while at late follow-up, AR had deteriorated to grade III in two of them, although no reoperation has been required so far. In chronic type A aortic dissection (n=38), 14 patients had AR grade II or greater (37%), of whom 11 had AR grade III or greater (29% vs. 13% in acute dissection; P=0.051). In 15 patients, dissection was found below the STJ and 12 patients had AR grade II or greater (80% vs. 48% in acute dissection; P=0.043). The aortic valve was replaced in eight patients (21% vs. 7% in acute dissection; P=0.051), including three Marfan patients. Of those whose aortic valve was preserved (n=30), two patients required reoperation for severe AR. The freedom from postoperative AR grade III or greater was 89% at 5 years for operative survivors with acute dissection and 92% for those with chronic dissection, respectively. CONCLUSIONS: This retrospective study suggests that preservation of the aortic valve in acute type A aortic dissection is feasible in non-Marfan patients regardless of the degree of AR. In chronic dissection, aortic root replacement needs to be considered when the degree of AR is greater than moderate because of a dilated STJ and/or annulus. In both acute and chronic dissections, satisfactory mid- to long-term results with a low incidence of reoperation were obtained in those whose aortic valve was preserved.     

Aortic insufficiency secondary to aortic root aneurysm or dissection.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.     

Ascending vs descending aortic dissections.

One hundred eight patients with spontaneously developing thoracic aortic dissection were seen between 1966-1973, 78 of whom had acute dissection and 30 chronic. The age (49 vs 60 yrs) and incidence of hypertension (32% vs 71%) were significantly lower in the 56 patients in whom dissection originated in ascending aorta than in the 52 patients in whom the dissection originated in the upper descending aorta. The mortality rate in medically treated patients with acute ascending aortic dissection was 88%. Cardiac tamponade was the major cause of death. The mortality rate was significantly lower in those who were treated surgically (24%). Fifteen (54%) of the patients with ascending aortic dissection and significant aortic incompetence did not have aortic valve replacement and only two subsequently (53 and 92 months later) required valve replacement. Although the initial mortality in patients with acute descending aortic dissection treated medically and surgically was similar, the long term survival rate was higher in the surgically treated group. We conclude that ascending aortic dissection and descending aortic dissection have different clinical profiles and prognoses. Immediate surgical intervention is indicated in patients with acute ascending aortic dissection. Patients with acute descending aortic dissection can be treated medically initially followed by early elective operation.     

Aortic valve sparing operations: an update

Background. Aortic valve sparing operations in patients with ascending aorta and/or aortic root aneurysms have been performed for a decade in our institution. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve. This article is an update on the clinical results of these operations.

Methods. From May 1988 to December 1997, 126 patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency underwent replacement of the ascending aorta with reconstruction of the aortic root and preservation of the native aortic valve. There were 85 men and 41 women, with a mean age of 54 years (range, 14 to 84). Thirty-two patients had the Marfan syndrome; 17 patients had acute and 10 had chronic type A aortic dissection; 23 had a transverse arch aneurysm; 26 had coronary artery disease, and 8 had mitral regurgitation. The aortic valve sparing operation consisted of simple adjustment of the sinotubular junction in 33 patients, adjustment of the sinotubular junction and replacement of one or more aortic sinuses in 60, and reimplantation of the aortic valve in a tubular Dacron (C.R. Bard, Haverhill, PA) graft in 33. Fifteen patients also had repair of aortic leaflet prolapse. Only 4 patients had a bicuspid aortic valve.

Results. There were 3 operative deaths due to cardiac failure. Patients were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular and 4 from unrelated causes. The actuarial survival was 72 ± 8% at 7 years. Two patients required aortic valve replacement; the freedom from aortic valve replacement was 97 ± 2% at 7 years. Doppler echocardiography revealed absent, trivial or mild aortic insufficiency in most patients; only 9 patients had moderate aortic insufficiency.

Conclusions. Aortic valve sparing operations are feasible in most patients with ascending aorta and/or aortic root aneurysms who have normal or near normal aortic leaflets. The functional results of the repaired aortic valve are excellent, and the repair appears to be durable.     

Single-stage reoperative repair of chronic type A aortic dissection using the arch-first technique

BACKGROUND: Management of the enlarged, chronically dissected aorta after previous repair of acute ascending aortic dissection or after a previous cardiac operation may present a formidable technical challenge and the optimal method of management is not clearly established. METHODS: Twenty-one patients with chronic type A aortic dissection (mean age 57 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. Single-stage replacement with perfusion of the aortic arch first to minimize the duration of brain ischemia and a bilateral anterior thoracotomy (clamshell) incision were used. Fourteen patients had undergone previous repair of acute type A dissection. Seven patients had type A dissection after aortic valve replacement (3 patients) or coronary artery bypass (4 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a two-stage repair. The mean interval between the initial and reoperative procedures was 69 months (range, 5 to 249). RESULTS: There was 1 (4.8%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Ten patients required assisted ventilation for more than 48 hours. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. There has been 1 late death (mean follow-up 2 years). CONCLUSIONS: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.     

Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

A new paradigm in the management of acute type A aortic dissection: Total aortic repair

The currently accepted guidelines of open surgical repair for acute type A aortic dissection include the resection of the primary entry tear, replacement of the ascending aorta and “hemi-arch” with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim is protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centers. Although this may sound to be a compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical paradigm, which aims to achieve total aortic healing in the acute phase. We describe a total aortic repair technique for acute type A aortic dissection consisting of “branch first” total arch repair, followed by thoracoabdominal stenting and balloon rupture of the septum. The total aortic repair technique ensures that the aortic valve, ascending aorta, and arch are surgically securely repaired, and provides complete decompression of the false lumen as well as internal support in the remainder of the aorta. This has provided excellent early results and will hopefully minimize future complications and interventions.     

Surgical treatment of aneurysms of the ascending aorta associated with severe aortic regurgitation

From January 1979 to June 1982 31 patients have had simultaneous ascending aortic aneurysm repair and aortic valve replacement. Fifteen patients (group 1) received a composite graft; seven patients (group 2) had separate aortic valve and supracoronary ascending aorta prostheses; and nine patients (group 3) had aortic valve replacement and "tailoring" of the ascending aorta. The mean age was 50 (SD 14) years. Nine patients had acute dissection, five with the coronary ostia affected. Emergency surgery was performed in 10 cases. There were six early deaths (19.4%), none of them due to technical complications during surgery. The mortality rate was 56% for patients with acute dissection operated on as an emergency and 4.5% for patients having elective operations. Appreciable haemorrhage occurred in four patients (12.9%). No neurological complications occurred. There was one late death. The survivors were followed up for one to four years. There was one case of recurrence of aneurysm. No ischaemic complications resulted from coronary reimplantation. There were no significant differences in the results of the three groups. Simultaneous ascending aortic aneurysm repair and aortic valve replacement can be accomplished with an acceptable mortality rate and little morbidity.     

Single-stage reoperative repair of chronic type A aortic dissection by means of the arch-first technique

OBJECTIVE: Management of the enlarged, chronically dissected aorta after previous repair of acute aortic dissection or after a previous cardiac operation may present a formidable technical challenge. Marked enlargement of the proximal descending thoracic aorta precludes safe use of staged procedures, including the elephant trunk technique. METHODS: Sixteen patients with chronic type A aortic dissection (mean age, 56 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. We used single-stage replacement, with perfusion of the aortic arch first to minimize the duration of brain ischemia, with a bilateral anterior thoracotomy (clamshell) incision. Eleven patients had undergone previous repair of acute type A dissection. Five patients had type A dissection after aortic valve replacement (2 patients) and coronary artery bypass (3 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a 2-stage repair. The mean interval between the initial and reoperative procedures was 62 months (range, 5-137 months). RESULTS: There was 1 (6.2%; 70% confidence limits, 0.3%-24.7%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Six patients required assisted ventilation for more than 72 hours, and 3 patients required a tracheostomy. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. CONCLUSION: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.     

Ross procedure for ascending aortic replacement

Background. Patients with aortic valve disease and aneurysm or dilatation of the ascending aorta require both aortic valve replacement and treatment of their ascending aortic disease. In children and young adults, the Ross operation is preferred when the aortic valve requires replacement, but the efficacy of extending this operation to include replacement of the ascending aorta or reduction of the dilated aorta has not been tested.

Methods. We reviewed the medical records of 18 (5.9%) patients with aortic valve disease and an ascending aortic aneurysm and 26 (8.5%) patients with dilation of the ascending aorta, subgroups of 307 patients who had a Ross operation between August 1986 and February 1998. We examined operative and midterm results, including recent echocardiographic assessment of autograft valve function and ability of the autograft root and ascending aortic repair or replacement to maintain normal structural integrity.

Results. There was one operative death (2%) related to a perioperative stroke. Forty-two of 43 survivors have normal autograft valve function, with trace to mild autograft valve insufficiency, and one patient has moderate insufficiency at the most recent echocardiographic evaluation. None of the patients has dilatation of the autograft root or of the replaced or reduced ascending aorta.

Conclusions. Early results with extension of the Ross operation to include replacement of an ascending aortic aneurysm or vertical aortoplasty for reduction of a dilated ascending aorta are excellent, with autograft valve function equal to that seen in similar patients without ascending aortic disease.     

Aortic intramural hematoma with severe aortic regurgitation

A 71-year-old Japanese woman with severe chest pain was diagnosed with Stanford type A acute aortic dissection. After 3 months of medical treatment, she was operated on under a diagnosis of dissecting aneurysm of the ascending aorta and severe aortic regurgitation. Operative findings showed prolapse, of the redundant aortic leaflets and a dilated ascending aorta without intimal tears. Operative and computed tomography findings differed from those of a classical dissection which was the primary diagnosis of this patient, and were compatible with a diagnosis of aortic intramural hematoma (IMH). Few reports of IMH include concomitant aortic regurgitation. Surgery involved aortic root remodeling and prosthetic graft replacement of the ascending aorta.     

Reduced survival in women after valve surgery for aortic regurgitation: effect of aortic enlargement and late aortic rupture

OBJECTIVE: We sought to investigate the relationship of female sex, aortic pathology, and left ventricular function to outcome after an operation for aortic regurgitation. METHODS: One hundred nine women underwent aortic valve replacement (n = 92) or repair (n = 17) for pure aortic regurgitation between 1985 and 1996. Mean follow-up was 5.7 +/- 2.6 years. New York Heart Association functional class III-IV symptoms were present in 70 patients, whereas left ventricular function was normal in 60 patients. Ascending aortic diameter in 97% exceeded the 90th percentile for a size-matched healthy population. A concomitant aortic operation was performed by means of root replacement in 31 patients and by means of interposition graft in 28 patients. Of 50 patients undergoing isolated valve procedures, 19 had aortas of 4.0 cm or larger. RESULTS: At 5 and 10 years, survival was 78% and 44%, respectively. Fatal aortic rupture occurred in 13 patients, and 2 others underwent emergency operations for impending aortic rupture, for a total of 15 late aortic events. Freedom from aortic events was 87% and 76% at 5 and 10 years, respectively. Risk factors for aortic events were older age (P =.07) and increasing ascending aortic diameter indexed to body surface area (P =.03) in women who had not undergone replacement of the ascending aorta. Rupture location was at the ascending aorta in 71% without ascending replacement and the descending aorta in 62% with ascending grafts. CONCLUSION: In women, late survival after an operation for aortic regurgitation is importantly decreased by coexisting aortic pathology with subsequent aortic rupture. Aortic replacement at the time of a valve operation should be considered on the basis of indexed aortic size.