Surgical management for active infective endocarditis: A single hospital 10 years experience

Objective  Surgical treatment of active infective endocarditis (IE) requires not only homodynamic repair, but also, special emphasis on the eradiation of the infection to prevent recurrence. This study was undertaken to examine the outcome of surgery for active infective endocarditis. Methods  One hundred sixty-four consecutive patients (pts) underwent valve surgery for active IE in Madani Heart Centre (Tabriz, Iran) from 1996 to 2006. Patients presenting with IE diagnosis (according to Duke Criteriaset) were eligible for study. Results  The mean age of patients was 36.3±16 years overall: 34.6±17.5 years for native valve endocarditis and 38.6±15.2 years for prosthetic valve endocarditis (p=0.169). Ninety one (55.5%) of patients were men. The infected valve was native in 112 (68.3%) of patients and prosthetic in 52 (31.7%). In 61 (37%) patients, no predisposing heart disease was found. The aortic valve was infected in 78 (47.6%), the mitral valve in 69 (42.1%), and multiple valves in 17 (10.3%) of patients. Active culture-positive endocarditis was present in 81 (49.4%) whereas 83 (50.6%) patients had culture-negative endocarditis. Staphylococcus aureus was the most common isolated microorganism. Ninety patients (54.8%) were in NYHA classe III and IV. Mechanical valves were implanted in 69 patients (42.1%) and bioprostheses in 95 (57.9%), including homograft in 19 (11.5%). There were 16 (9%) operative deaths, but there was only 1 death in patients that underwent aortic homograft replacement. Reoperation was required in 18 (10.9%) of cases. On multivariate logistic regression analysis, Staphylococcus aureus infection (p=0.008), prosthetic valve endocarditis (p=0.01), paravalvular abscess (p=0.001) and left ventricular ejection fraction less than 40% (p=0.04) were independent predictors of inhospital mortality. Conclusions  Surgery for infective endocarditis continues to be challenging and associated with high operative mortality and morbidity. Prosthetic valve endocarditis, impaired ventricular function, paravalvular abscess and Staphylococcus aureus infection adversely affect in-hospital mortality. Also we found that aortic valve replacement with an aortic homograft can be performed with acceptable in hospital mortality and provides satisfactory results.     

Dural Arteriovenous Shunts in the Region of the Cavernous Sinus1

Two cases of carotid-cavernous fistula are presented. The departure from the classical picture is described, with emphasis on the radiological diagnosis. The ætiology of these fistulæ is uncertain, but several theories are discussed.     

THE CREATION OF ARTIFICIAL SUBCUTANEOUS ARTERIOVENOUS FISTULAS IN PATIENTS WITH MALIGNANT HEMATOLOGICAL DISEASE

Creation of an artificial subcutaneous arteriovenous fistula was attempted in five patients with malignant hæmatological disorders (two with Hodgkin's disease, two with acute lymphatic leukæmia, and one with acute myeloid leukæmia). The average time from the start of treatment to attempted creation of the fistulæ was four years. Neither direct arteriovenous anastomosis nor an interposition mandril graft was successful in any patient. Failure was attributed to impaired venous run-off secondary to previous episodes of thrombophlebitis induced by the intravenous administration of cytotoxic drugs. The use of an arteriovenous fistula early in the course of the disease might minimize these later problems.     

The surgical treatment of fixed subaortic stenosis: A clinical experience in Japan

P = 0.0017). Reoperation of an aortic valve replacement with or without valvular annulus enlargement was required in four patients because of a small annulus with aortic insufficiency or infective endocarditis. Infective endocarditis was a major cause of late mortality (n = 1) and morbidity (n = 1), but the remaining eight patients have been asymptomatic. Thus, although this lesion is relatively rare in Japan, the typical discrete type may be more common than previously believed. While a relief operation is associated with low early mortality, the palliative aspect regarding pathology of the aortic valve should not be underestimated, including poor growth of the valve annulus, deterioration of aortic insufficiency, and infective endocarditis. The most appropriate operative procedure for reoperation remains to be evolved. (Received for publication on Nov. 17, 1997; accepted on May 15, 1998)     

Medium-term results of aortic valve replacement with cryopreserved homograft valves: importance of a domestic homograft valve bank

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.     

Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis

Background. There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root.

Methods. From 1986 through 1998, 81 adults with aortic valve endocarditis underwent valve replacement (AVR). The mean age of the 65 men and 16 women was 44 ± 14 years. Sixty-three (78%) patients had active endocarditis at the time of operation. Non-native valve endocarditis was present in 29 (36%) patients, in 9 of whom the infection was a recurrence. Aortic valve replacements were performed with 46 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 11 required mitral valve replacement or repair (homo-Ross DVR). Follow-up was 90% complete within 2 years of the end of the study with a mean of 3.7 ± 3.4 years.

Results. Early mortality was 16% (13 of 81 patients). This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Overall late mortality was 10% (7 of 68 patients) with a valve-related late mortality of 7% (5 of 68 patients). Actuarial survival at 5 years was 88% ± 9% in Ross-AVR, 69% ± 11% in homo-AVR, and 29% ± 22% in prosth-AVR (p = 0.03). Endocarditis recurred in 12.5% (1 of 8 patients) with prosth-AVR and 3% (2 of 60 patients) in homo-Ross AVR.

Conclusions. Valve replacement in the presence of native and prosthetic endocarditis remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients even if concomitant mitral valve replacement is required, and risk of valve-related death or recurrent endocarditis is low at medium-term follow-up.     

Aortic root replacement with cryopreserved allograft for prosthetic valve endocarditis

BACKGROUND Our strategy has been to treat aortic prosthetic valve endocarditis (PVE) with radical debridement of infected tissue and aortic root replacement with a cryopreserved aortic allograft. This study examines the effectiveness of this strategy on hospital mortality and morbidity, recurrent endocarditis, and survival. METHODS: From 1988 through 2000, 103 patients with aortic PVE underwent root replacement with a cryopreserved aortic allograft. Abscesses were present in 78%, and aortoventricular discontinuity was present in 40%. Thirty-two patients had at least one previous operation for endocarditis. In 23 patients with a history of native valve endocarditis, the allograft was implanted after one episode (17 patients), two episodes (5 patients), or three episodes of PVE (1 patient). In the 80 patients without a history of native valve endocarditis, the allograft was placed after one previous aortic valve replacement (57 patients), two (19), or three (4) previous aortic valve replacements. Among the 92 patients with positive cultures, 52 had staphylococcal organisms, 20 had streptococcal, 6 had fungal, 4 had gram-negative, and 6 had enterococcal organisms. Mean follow-up was 4.3 +/- 2.9 years. RESULTS: Hospital mortality was 3.9%. Permanent pacemakers were required in 31 patients. Survival at 1 year, 2 years, 5 years, and 10 years was 90%, 86%, 73%, and 56%, respectively, with a risk of 5.3% per year after 6 months. Four patients underwent reoperation for recurrent PVE of the allograft (95% freedom from recurrent PVE at > or = 2 years). Risk of recurrent PVE peaked at 9 months and then declined to a low level by 18 months. CONCLUSIONS: A strategy of radical debridement and aortic root replacement with a cryopreserved aortic allograft for aortic PVE is safe, effective, and recommended.     

Active Native Valve Endocarditis: Determinants of Operative Death and Late Mortality

Background. In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993.

Methods. There were 201 male and 46 female patients (mean age, 45.4 ± 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (χ² test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival.

Results. Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% ± 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% ± 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found.

Conclusions. Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.     

Results of prosthetic valve replacement for aortic stenosis

Background: Aortic valve replacement with mechanical valves is associated with a small but constant risk of valve thrombosis and thromboembolic and hemorrhagic complications. The surgical outcome of patients with Aortic Stenosis who had aortic valve replacement with mechanical valves is reported here. Methods: Between January 1990 and October 1999, 275 patients underwent prosthetic valve replacement for isolated aortic stenosis. The age ranged between 13 years and 75 years and 230 were males. The cause of aortic stenosis was rheumatic in 185 patients (67.3%), followed by bicuspid aortic valve in 75 patients (27.3%) and degenerative in 15 patients (5.4%). Results: The early mortality was 1.5%. The follow up was 96% complete and ranged from 1 to 104 months (mean 54±24.5months). Six patients (2.2%) developed prosthetic valve endocarditis. Paravalvular leak occurred in 3 (0.9%) patients. Valve thrombosis occurred in 10 patients (1.0% per patient year). The actuarial survival was 81±7% at 5 years and 64±13% at 8 years. Event free survival was 40±14% at 8 years. Conclusion: With current operative techniques and myocardial preservation aortic stenosis patients are at low risk for surgery. However, long term survival is limited due to prosthesis related complications.     

Long-term survival after aortic valve replacement for native active infective endocarditis

Background: The objective of this study was to analyse the impact of acute surgery for native aortic valve endocarditis and its influence on the long-term prognosis after surgery. Methods: A total of 161 patients underwent aortic valve replacement for native active aortic valve endocarditis (NAAVE) during a 29-year period, from 1967 to 1995 (age range: 10 to 72 years; mean 48 ± 12). The main indication for surgery was progressive congestive heart failure (76%). Other indications were unbeatable sepsis (27%), peripheral or central emboli (12%) and, from 1978, echocardiographic evidence of friable, pedunculated vegetations (3%). Streptococcal and staphylococcal infections predominated. Concomitant procedures were performed in 27% of the patients, including mitral and tricuspid valve surgery and coronary bypass procedures. Results: Operative mortality was 8% in the majority of cases caused by heart failure or multiorgan failure. Multivariate logistic regression analysis identified NYHA class IV to be an independent predictor for postoperative death. Long-term survival for discharged patients was 75% at 10 years and 58% at 15 years, with a mortality rate of 3.6%/patient/year. Cox regression analysis identified the year of operation, trivalvular endocarditis and staphylococcal infection as independent predictors of survival. At 10 and 15 years after aortic valve replacement, 91% and 84% of the patients, respectively, were free of recurrent endocarditis. The presence of an abscess cavity at first operation was found to be predictive of recurrent endocarditis. Conclusions: Valve replacement for NAAVE offers a good chance for a cure and satisfactory long-term survival. Improvements in pre- and per-op-rative management of the very ill patient, and the use of allograft valves are likely to further improve long-term results. Finally, the presence of staphylococcal endocarditis requires long-term postoperative antibiotic therapy.     

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective

We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.

Methods

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.     

Risk factor analysis of hospital mortality in patients with endocarditis with ring abscess

Abstract Background: Endocarditis associated with ring abscess is a pathology with high morbidity and mortality. Aim of the study: The purpose of this study was to analyze hospital mortality risk factors in patients with ring abscess due to endocarditis. Methods: From January 1982 to December 2000, 104 patients underwent surgical intervention at the Heart Institute of the University of São Paulo Medical School for valve endocarditis with ring abscess. The age ranged from 6 years to 73 years, with an average of 40.3 years and 72.1% were male. According to NYHA functional class (FC), 12 (11.5%) were in FC II, 62 (59.6%) in FC III, and 30 (28.9%) in FC IV. Seventy‐seven (74.0%) patients had endocarditis on a bioprosthesis, 58 (55.8%) in the aortic position and 19 (18.3%) in the mitral position. Twenty‐nine (26.9%) patients had atrioventricular blockage prior to the operation. Univariate analysis was performed comparing variables and hospital mortality with a level of significance of 5%. Multivariate analysis was performed by logistic regression. Results: The hospital mortality was 19.2% (20 patients). Univariate analysis showed that atrioventricular blockage, age, and prosthetic valve endocarditis significantly influenced hospital mortality. Multivariate analysis identified atrioventricular blockage as an independent predictor of hospital mortality. Conclusions: Preoperative atrioventricular blockage is an independent risk factor for hospital mortality in the surgical treatment of endocarditis with ring abscess.     

Replacement of the aortic root for acute prosthetic valve endocarditis: prosthetic composite versus aortic allograft root replacement

OBJECTIVE: Aortic root replacement for prosthetic aortic valve endocarditis with accompanying destruction of the aortic root is a well-established surgical intervention. However, there is still no consensus whether prosthetic material or allogeneic material should be used. Here we report on our experience with prosthetic composite and aortic allograft root replacement in such patients during a 10-year interval. METHODS: From 1991 through 2001, 29 patients with prosthetic aortic valve endocarditis combined with aortic root destruction underwent reoperation at our institution. Sixteen patients received aortic root replacement with a cryopreserved aortic root allograft (group A) and 13 with a prosthetic composite graft (group B). The interval between the initial operation and reoperation was 29 months (range, 5-168 months) in group A and 55 months (range, 7-248 months) in group B. RESULTS: Hospital mortality was 18.5% (n = 5 patients, 3 in group A and 2 in group B). Median follow-up was 21 months (range, 1-48 months) for group A and 34 months (range, 1-152 months) for group B (P >.2). Survival at 1 and 5 years was 81% +/- 10% and 81% +/- 10% in group A and 85% +/- 10% and 85% +/- 10% in group B, respectively. No patient underwent reoperation for recurrent prosthetic aortic valve endocarditis. CONCLUSIONS: Our results indicate that excellent long-term results can be achieved regardless of the material used for aortic root replacement in patients with prosthetic aortic valve endocarditis.     

Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices

BACKGROUND: Operation for active infective endocarditis carries high mortality and morbidity rates, especially when the annulus is involved. Overall the literature favors the use of autograft and homograft valves because of better resistance to infection. In our clinic during the last 5 years we used an aggressive surgical approach to infective endocarditis in combination with implantation of mechanical or stented bioprosthetic devices. METHODS: From 1994 to 1999, 50 adults with aortic and/or mitral valve endocarditis underwent valve replacement. The median age of the 36 men and 14 women was 58 years (range, 17 to 78 years). All patients had active endocarditis at the time of operation. Native valve endocarditis was present in 48 patients and prosthetic valve endocarditis was present in 2 patients. The aortic valve was affected in 24 patients, the mitral valve in 21 patients, and both the aortic and mitral valves in 5 patients. Two of the patients with mitral endocarditis also had infection of the tricuspid valve. Annular destruction was present in 24 patients (48%). The patients were treated with radical excision of all infected tissue. The annular defects were closed, if possible, with direct sutures. Otherwise, a reconstruction was performed. Follow-up was 100% complete with a median follow-up period of 45 months (range, 6 to 66 months). RESULTS: The procedures were performed without lethal bleeding complications. Early mortality was 12% and the actuarial survival at follow-up was 80%. In none of the patients who died was death related to the prosthetic valve or recurrence of the endocarditis. Only 1 patient (2%) developed recurrence of the infective endocarditis and was reoperated with a Ross procedure. Three and a half years later the patient developed severe valve insufficiency of the autograft and was operated again with implantation of a mechanical device. CONCLUSIONS: Native and prosthetic valve endocarditis can be treated successfully with aggressive surgical debridement and implantation of mechanical or stented bioprosthetic devices with a low risk of recurrent endocarditis.     

Surgery of the aortic root: should we go for the valve-sparing root reconstruction or the composite graft-valve replacement is still the first choice of treatment for these patients?

Objective

To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.

Methods

From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.

Results

In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.

Conclusion

The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.     

Aortic Valve Replacement with Autologous Pericardium: Surgical Technique

The surgical technique of aortic valve replacement with freehand glutaraldehyde-treated autologous pericardium is described. Forty-nine patients underwent this procedure without hospital mortality and no thromboembolic episodes without anticoagulation. Three patients underwent reoperation: for infective endocarditis in two; and tear of one commissure 8 months after surgery in another. This technique because of its excellent hemodynamics and low thrombogenicity might be a valid alternative particularly in patients with a small aortic annulus.     

The surgical management of bacterial endocarditis: a review.

A total of 239 surgically treated patients with primary endocarditis were reviewed both from the literature and from our own experience. The age range was 10 to 74 years with a male to female ratio of 3:1. A wide variety of organisms was found. However, as a group, gram positive organisms predominate. The onset of congestive failure was the major indication for surgery. The aortic valve was predominantly involved with the mitral valve running a distant second. The hospital mortality rate was 20% and the late mortality rate was 6.7% with an overall mortality of 26.7%. The prognosis in infective endocarditis when congestive failure develops, even in the presence of antibiotic therapy, is poor (79-89% mortality). In view of this poor prognosis, an aggressive attitude with regard to early surgical intervention can greatly improve the outcome of valvular endocarditis.     

A case of abdominal aortic pseudoaneurysm associated with right heart mass

We present a patient with right-sided endocarditis associated with abdominal aortic pseudo-aneurysm presenting only with high fever and pulsating abdominal mass. A higher clinical awareness of aortic pseudoaneurysms associated with intracardiac lesions disease, leading to early computed tomography evaluation and prompt surgical intervention appears to offer the best chance of survival. In this aspect, single-stage surgical treatment of both endocarditis and the aortic pathology is necessary.     

Cryopreserved aortic allografts for aortic root reconstruction: a single institution’s experience

Background. An evaluation of early and long-term results of aortic root replacement with cryopreserved aortic allografts and echocardiographic follow-up of allograft valve function was performed.

Methods. From September 1989 through May 1998, 132 patients aged 17 to 77 years (mean, 50.8 ± 14.8 years) underwent freestanding aortic root replacement with a cryopreserved aortic allograft. Eighty-six (65.1%) patients had New York Heart Association class III or IV functional status before operation, and 27 (20.5%) patients underwent emergency operation. Fifty-nine (44.7%) patients had undergone previous cardiac operations. The cause of aortic disease was acute endocarditis in 63 (47.7%) patients, healed endocarditis in 15 (11.3%), degenerative in 20 (15.2%), congenital in 20 (15.2%), failed prosthesis in 10 (7.6%) and rheumatic in 4 (3.0%). Follow-up was complete, with a mean of 42 months.

Results. There were 12 hospital deaths (9.1%; 70% confidence limits [CL], 6.6% and 11.6%); 9 of them were operated on for active endocarditis (p = 0.062). Multivariate analysis determined age older than 65 years (p = 0.012) and emergency operation (p = 0.009) as independent risk factors for hospital mortality. During follow-up, 6 (5.0%; 70% CL, 3.0% and 7.0%) patients died. Cumulative survival rate for the entire group was 81.8% ± 5.4% at 8 years. Freedom from reoperation for structural valve failure was 100%, freedom from reoperation for any cause was 96.3% ± 1.8% at 8 years. Freedom from endocarditis at 8 years was 97.9% ± 1.4%. Follow-up of allograft valve function showed no or trivial aortic regurgitation in 97% of patients and absence of stenosis of the allograft in 100%.

Conclusions. Aortic root replacement with cryopreserved aortic allografts can be performed with acceptable hospital mortality and long-term results. The durability of cryopreserved aortic allografts is good, and reoperation for structural valve failure is absent at 8 years.     

SURGICAL REPAIR OF TYPE-A AORTIC DISSECTION: EARLY AND LATE RESULTS IN 32 CONSECUTIVE PATIENTS

Background : Acute type-A aortic dissection is a surgical emergency. One unit's experience in the surgical repair of type-A aortic dissection is documented. Methods : Surgical treatment was undertaken for type-A aortic dissection in 32 consecutive patients between January 1988 and August 1994 at Royal North Shore Hospital. Retrosternal chest pain was the commonest presenting symptom and in four of these cases it was initially misinterpreted as myocardial ischaemia. Results : A total of 24 patients had signs of aortic incompetence on presentation. Computed tomography (CT) scanning was the commonest modality of definitive diagnosis, but trans-oesophageal echocardiography was used as confirmation wherever possible, and we now consider it the initial, best investigation whenever a diagnosis of dissection is considered. There were 15 supra-coronary ascending aortic replacements, and a further four with aortic valve re-suspension. There were 13 operations of the Bentall's type. The overall 30-day mortality was 19%. The late mortality was 19%. with 62% long-term survival at a mean follow-up of 4.8 years. Conclusion : Early diagnosis and surgical intervention can give excellent palliation and improved life expectancy in acute type-A aortic dissection.