Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta

Objectives

We sought to compare the clinical profile and outcomes of operations for aortic valve disease and ascending aortic aneurysm in patients treated with aortic valve replacement and supracoronary replacement of the ascending aorta or composite replacement of the aortic valve and ascending aorta (Bentall operation).

Methods

From 1990 through 2001, 133 patients had aortic valve replacement and supracoronary replacement of the ascending aorta, and 452 patients had Bentall operations. Aortic valve replacement and supracoronary replacement of the ascending aorta was performed in patients who had aortic valve disease and dilation of the ascending aorta, whereas the Bentall operation was performed in patients with aortic root abnormality and ascending aortic aneurysm. Mean follow-up was 4.6 ± 3.1 years and was 100% complete.

Results

Patients who had aortic valve replacement and supracoronary replacement of the ascending aorta were older (61 ± 13 vs 52 ± 16 years, P < .001) and more likely to have aortic stenosis, coronary artery disease, and mitral valve disease than those who had Bentall operations. The use of mechanical valves was equal in both groups (42% for aortic valve replacement and supracoronary replacement of the ascending aorta and 43% for the Bentall operation). Operative mortality was 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 4% for patients undergoing the Bentall operation (P = .45). Survival at 10 years was 57% ± 8% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 74% ± 4% for patients undergoing the Bentall operation (P = .04), but the type of operation had no effect on survival. Older age, moderate or severe left ventricular dysfunction, active endocarditis, previous cardiac surgery, and coronary artery disease were independent predictors of death. The freedom from reoperation at 10 years was 95% ± 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 94% ± 3% for patients undergoing the Bentall operation (P = .18). Reoperations were mostly because of tissue valve failure or endocarditis. The risk of valve-related complications was the same in both groups. No patient required reoperation for aortic root aneurysm after having aortic valve replacement and supracoronary replacement of the ascending aorta.

Conclusions

Aortic valve replacement and supracoronary replacement of the ascending aorta and the Bentall operation provide comparable long-term results. The Bentall operation is more appropriate for patients with aortic root abnormality and a dilated ascending aorta, whereas aortic valve replacement and supracoronary replacement of the ascending aorta is a perfectly acceptable operation for patients with aortic valve disease, normal or mildly dilated aortic sinuses, and a dilated ascending aorta.     

Reoperative cryopreserved root and ascending aorta replacement for acute aortic prosthetic valve endocarditis

BACKGROUND: Prosthetic aortic valve endocarditis (PVE) is an important complication of aortic valve replacement (AVR) and is a particularly difficult situation after an operation combining AVR with ascending aortic replacement. METHODS: From 1988 through 2000, 27 patients with aortic valve PVE after previous ascending aortic replacement (aortic root replacement in 13, aortic valve replacement with a supracoronary graft in 14) underwent reoperation for aortic root replacement with a cryopreserved aortic allograft and prolonged intravenous antibiotic therapy. All patients were considered to have active PVE (25 with positive cultures); root abscess formation was present in 89% and aortoventricular discontinuity in 41%. RESULTS: One patient (3.7%) died in-hospital, and permanent pacemakers were required in 10 patients (37%). Mean postoperative follow-up interval was 3.9 +/- 3.0 years, and survival at 1, 2, 5, and 7.5 years was 92%, 88%, 70%, and 56%, respectively. One patient underwent reoperation for recurrent PVE 8 months after operation. CONCLUSIONS: Radical debridement of infected prosthetic material and tissue, and allograft aortic root and ascending aorta replacement, combined with intravenous antibiotic therapy, appears to achieve a low hospital mortality and a high degree of freedom from recurrent infection for patients with PVE after AVR and ascending aortic replacement.     

Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated?

BACKGROUND: The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval. METHODS: Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1). RESULTS: Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months. CONCLUSIONS: These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.     

Reoperations on the aortic valve combined with replacement of the ascending aorta

OBJECTIVE: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. PATIENTS AND METHODS: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. RESULTS: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%+/-4% for patients who had composite replacement of the aortic valve and ascending aorta. CONCLUSIONS: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

Reoperations on the Aortic Valve Combined with Replacement of the Ascending Aorta

ABSTRACT Objective: To review the experience with reoperations on the aortic valve combined with replacement of the ascending aorta. Patients and Methods: From 1991 to 2000, 237 patients underwent reoperations on the aortic valve combined with replacement of the ascending aorta. The study consisted of 188 men and 49 women, with a mean age of 51 years. The operation was urgent or emergent in 44% of cases. Many patients (42%) were in New York Heart Association Class IV, and 24 had active infective endocarditis. The ascending aorta was replaced previously in 46 patients, while the remaining patients had aneurismal dilation. An aortic valve sparing operation was performed in 14 patients and aortic valve replacement in 223. The ascending aorta was replaced in all patients as follows: as a composite graft in 166 and supracoronary in 71. Mechanical valves were used in 145 (61%) patients. Results: The operative mortality was 9%. Postoperative complications were common and 30% of patients suffered an adverse event (death or complication). No independent predictor of operative mortality could be identified but urgent/emergent surgery, advanced functional class, infective endocarditis, coronary artery disease, and replacement of the transverse aortic arch were associated with higher operative mortality by chi-square analysis. The survival at 5 years was 74%± 4% for patients who had composite replacement of the aortic valve and ascending aorta. Conclusions: Reoperations on the aortic valve combined with replacement of the ascending aorta can be performed with acceptable operative risk and good mid-term survival.     

Cylindrical patch repair for circumferential subvalvular abscess due to prosthetic valve endocarditis

A 51-year-old male underwent aortic valve replacement and vascular prosthesis implantation due to an aneurysm of the ascending aorta combined with aortic regurgitation caused by the bicuspid aortic valve. Semi-emergency surgery was performed due to severe paravalvular leakage with prosthetic valve endocarditis 16 months after the 1st operation. The circumferential annular abscess cavities were closed with a cylindrical patch, and a mechanical valve was installed on the upper edge of the sutured cylindrical patch. A vascular prosthesis was reimplanted to the ascending aorta. Use of the cylindrical patch provides a good exposure of operative field to close circumferential annular abscess cavity.     

主动脉瓣重度狭窄171例外科治疗分析

目的 总结主动脉瓣重度狭窄行瓣膜置换术患者的外科治疗经验.方法 1990年12月至2006年12月共有171例主动脉瓣重度狭窄患者接受主动脉瓣置换术.其中男性135例,女性36例;年龄10-75岁,平均(45.8±15.6)岁;病程2个月-52年.主动脉瓣病变的病因依次为风湿性75例、老年性66例、二叶瓣畸形26例及其他先天性主动脉瓣畸形4例.单独主动脉瓣置换124例,主动脉瓣置换+升主动脉置换7例,主动脉瓣置换+冠状动脉旁路移植5例,主动脉瓣置换+二尖瓣成形19例,主动脉瓣置换+升主动脉成形8例,主动脉瓣置换+主动脉根部拓宽8例(Nicks法).结果 全组患者平均手术时间(4.4±0.6)h,心肺转流时间(124.7±38.5)min,其中主动脉阻断时间(78.3±21.7)min,术中平均出血量(754.5±518.4)ml,所有患者均顺利完成手术并脱离心肺转流.术后早期并发症发生率为12.3%(21/171),包括低心排血量综合征7例,多脏器功能衰竭3例,心内膜炎1例,肾功能不全4例,心室颤动1例,开胸止血2例,Ⅲ度房室传导阻滞2例,纵隔感染1例.全组手术死亡率5.8%(10/171),死于心力衰竭4例,心律失常1例,多脏器功能衰竭4例,感染性心内膜炎1例.结论 主动脉瓣重度狭窄患者的外科治疗对手术技术及围手术期处理经验要求较高,积极行瓣膜置换手术效果满意.     

Annular destruction in acute bacterial endocarditis. Surgical techniques to meet the challenge

Destruction and disruption of ventricular-aortic or mitral-aortic continuity in the presence of acute infection of the annular tissue is a significant surgical challenge. Among 82 patients who underwent surgical treatment for acute endocarditis over a 10-year period, 15 (18.2%) had extensive destruction of the anulus necessitating special reconstructive techniques for treatment. Surgical treatment involved removal of all infected tissue including annular elements followed by appropriate restoration of the anulus for safe anchoring of the prosthetic valve. The reconstruction of the anulus consisted of the following: a Teflon felt patch inside and outside the aorta or ventricle, or both, for secure attachment of the prosthesis (felt aortic root, in three patients with native valve endocarditis), valved composite graft replacement of the aortic root for ventricular-aortic discontinuity (Bentall procedure, in eight patients with prosthetic valve endocarditis), composite patch reconstruction of the mitral anulus and the ascending aorta to restore mitral-aortic continuity (mitral-aortic composite patch in two patients with mitral-aortic prosthetic valve endocarditis), and direct suture of the sewing skirts of the mitral and aortic prostheses to restore the defect (attached skirts, in one patient with mitral-aortic native valve endocarditis). There was one hospital death caused by multiple organ failure. The most common complication was heart block. Two late deaths were due to reinfection resulting from continued intravenous drug abuse. One patient with a felt aortic root repair required late reoperation for subannular aneurysm. Eleven patients were followed up from 7 months to 66 months and are alive and well without complications. This experience indicates that these seemingly radical surgical techniques can be used in these desperately ill patients with safety and good long-term results. They offer the only lasting solution for major disruption in cardiac anatomy in the presence of infection.     

Surgical Treatment of Prosthetic Valve Endocarditis with Homograft Aortic Valve Replacement

This article presents the University of Alabama experience with homograft aortic valve replacement for prosthetic valve endocarditis. Of 117 patients who have undergone homograft aortic valve replacement since 1981, there has been a total of 22 patients who underwent operation for endocarditis. Sixteen were isolated valve replacements, three combined with other procedures, and three were aortic root replacements. When placed in a setting of active endocarditis, there have been no reoperations for endocarditis of the homograft valve. Surgical techniques are presented for the freehand sewn homograft as well as aortic root replacement. Prosthetic valve endocarditis is a highly lethal event and when aortic valve replacement is advised in this setting, we believe a homograft aortic valve should be implanted whenever possible.     

Redo aortic root replacement: experience with 31 patients

BACKGROUND: Aortic root re-replacement is being performed with increased frequency. Limited information is available regarding the surgical approaches and clinical outcomes of this reoperation. METHODS: Between May 1980 and May 1999, 31 patients (mean age, 45 +/- 15 years) underwent redo composite replacement of the aortic valve and ascending aorta. Indications for reoperation were prosthetic valve endocarditis in 12 patients (39%), failed biological valve in 17 (55%), and false aneurysm in 2 (6%). At reoperation, mechanical valves were implanted in 24 patients and biologic valves in 7. All patients with endocarditis had annular abscess and required reconstruction of the left ventricular outflow tract before implantation of a new valved conduit. Mechanical valves were used in 24 patients, aortic homograft in 4, and bioprosthetic valves in 3. The coronary button technique was used to reimplant the coronary arteries whenever possible. Extension of one or both coronary arteries with a short segment of saphenous vein or a synthetic graft was used in 16 patients (52%). The aortic arch was replaced in 7 patients (23%). RESULTS: There was one operative death (3%) because of rupture of an abdominal aortic aneurysm. The mean follow-up was 47 +/- 46 months and was 100% complete. There were five late deaths (16%), three of which were cardiac related. The actuarial survival was 71% +/- 12% at 5 years. Three patients experienced recurrent prosthetic valve endocarditis 4 months to 8 years after operation. The 8-year freedom from endocarditis for patients operated on for endocarditis was 82% +/- 11% compared with 100% for those operated on for other reasons (p = 0.1). At the last follow-up, 21 of 25 survivors (84%) were in New York Heart Association functional classes I or II, and 4 were in class III. CONCLUSIONS: Redo aortic root replacement can be performed with good early and late results. Patients operated on for prosthetic root endocarditis may have an increased risk of recurrent late endocarditis.     

Cardiac reoperation in a patient with osteogenesis imperfecta: a case report.

A case of a 40-year-old man with dehiscence of the prosthetic aortic valve and recurrence of mycotic aneurysm of the left ventricular outflow tract with osteogenesis imperfecta is presented. He had an operation of aortic valve replacement and direct closure of the mycotic aneurysm for infective endocarditis twenty-one months ago. We performed reoperation of prosthetic aortic valve, patch closure of the mycotic aneurysm and graft replacement of the ascending aorta. He was complicated with multiple fractures of bilateral scapla and dislocation of left shoulder one postoperative day. Fortunately, cardiac reoperation was performed successfully in this patient despite anticipated difficulties with tissue friability with osteogenesis imperfecta.     

Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients

BACKGROUND: This analysis was performed to evaluate the results of reoperations on the ascending aorta and aortic root. METHODS: All reoperations (n = 134) on the aortic root and ascending aorta performed between February 1981 and April 1998 were retrospectively analyzed. Indications for reintervention were a true or false aneurysm (35%), acute dissection (3.0%), aortic valve stenosis and/or insufficiency (23.1%), prosthetic valve endocarditis (32.8%), and combinations (4.5%). The principal reoperations performed were aortic root replacement (composite graft, freestyle, aortic allograft, or pulmonary autograft) in 116 patients, ascending aortic replacement in 10 patients, and closure of a false aneurysm in 5 patients. Results were analyzed using univariate statistical methods. RESULTS: Hospital mortality was 6.6% (8 patients). Univariate predictors of hospital death were preoperative functional class III or IV (p = 0.02), an interval of less than 6 months between the primary and actual operation (p = 0.02), preoperative creatinine level of more than 200 micromol/L (p = 0.001), acute aortic dissection (p = 0.001), intraoperative technical problems (p = 0.001), and postoperative dialysis (p = 0.001). Freedom from repetitive reoperation was 99% at 1 year and 98% at 5 and 10 years. CONCLUSIONS: Reoperations on the aortic root and ascending aorta can be performed with an early mortality which is very acceptable.     

Bartonella infective endocarditis of a prosthetic aortic valve with a subvalvular abscess

A patient with a prosthetic aortic valve, and culture negative endocarditis caused by Bartonella henselae presented with nonspecific constitutional symptoms, skin rash, and then later developed acute renal failure. The patient underwent redo sternotomy, aortic root, and ascending aorta replacement with a homograft, which resolved his symptoms and the renal failure.     

Ascending aortic infected pseudoaneurysm with aortic insufficiency following cardiac operation for infective endocarditis.

An infected pseudoaneurysm of the ascending aorta after heart surgery is a fatal disease due to its rapid progress, worsening of the systemic condition and a tendency of recurrence. We report a 53-year-old man with this condition who presented with fever and an aortic regurgitation due to compression of the ascending aortic root 2 months after mitral valve replacement for infective endocarditis. We performed an aneurysmectomy with a cardiopulmonary bypass using groin cannulation and moderate systemic hypothermia. A pseudoaneurysm developed 5 mm proximally of the previous aortotomy. There was no dehiscence of the former aortic suture line. After debridement of the ascending aorta involving the previous aortotomy and pseudoaneurysm, we elected to directly close the aortic defect using Teflon felt strips to avoid a prosthetic graft. The aortic valve had no infective endocarditis and other abnormality. Postoperatively, there was no aortic regurgitation, and the cause of the previous aortic regurgitation was believed to be due to a compression of the aortic root from outside. The postoperative course has been good.     

Aortic valve replacement for Takayasu's arteritis.

We report 12 cases of aortic valve replacement performed for Takayasu's arteritis and discuss the genesis of aortic regurgitation and the clinical outcome after aortic valve replacement. This group of twelve patients who underwent aortic valve replacement between April 1982 and March 1990 included four male and eight female patients, aged 24 to 67 years (mean age 48 years). Preoperative angiography showed systemic multiple stenoocclusive or aneurysmal dilated vascular lesions in addition to aortic regurgitation. The multiple lesions included a lesion in the aortic arch branch in nine (75%), in the pulmonary artery in seven (58%), an aneurysmal dilation in the ascending aorta of more than 6 cm in four (33%), a coronary lesion in four (33%), a thoracic aortic lesion in six (50%), and a lesion in the abdominal aorta and its visceral branch in six (50%). Simple aortic valve replacement alone was performed in two patients and in combination with another operation in ten patients, with aortic root reconstruction in two, ascending aortic plication in three, coronary artery bypass grafting in two, aortic arch branch bypass grafting in one, aortic arch branch bypass grafting and coronary ostium endarterectomy in one, and mitral valve replacement and ascending aortic plication in one. There was no operative death, and only one patient died later, 18 months after the operation, because of secondary amyloidosis. The postoperative recovery of the clinical status and cardiac function was good. Intraoperative observations suggested that aortic valve regurgitation may be caused by an extension of aortitis, although histopathologic examinations of the valve showed nonspecific findings. One of the characteristic problems in Takayasu's arteritis is the necessity for prednisolone administration in some patients preoperatively or postoperatively, or both. We conclude that aortic valve replacement for patients with Takayasu's arteritis is an effective and safe treatment. Our data related to the genesis of aortic regurgitation in Takayasu's arteritis remain insufficient to draw conclusions, and further analysis is planned.     

Surgery of the dilated aortic root and ascending aorta in pediatric patients: techniques and results.

OBJECTIVE: Dilatation of the aortic root is a well-known cardiovascular manifestation in children and adult patients with connective tissue disease (e.g. Marfan syndrome). Dilatation of the ascending aorta is extremely rare and may be associated with bicuspid aortic valve. This report evaluates the incidence of dilatative aortic root and ascending aortic pathology in patients younger than 18 years and analyzes the results obtained after repair and replacement strategies. METHODS: Between 1/1995 and 12/2002, a total of 752 operations on the thoracic aorta were performed in adult and pediatric patients. We present our experience with a group of 26 patients <18 years of age, who required isolated surgery of the aortic root and/or ascending aorta because of a dilatative lesion. Fifteen patients had isolated aortic root dilatation (13 of them suffered from Marfan syndrome), eight patients presented with an idiopathic dilatation of the ascending aorta and three patients had dilatation in association with a bicuspid aortic valve. Mean age was 10 +/- 4.8 years (4-18 years). Repair of the aortic root with preservation of the aortic valve (Yacoub, David or selective sinus repair) was performed in nine patients, replacement using a homograft was performed in five patients, composite graft with mechanical prosthesis in two patients, with biological prosthesis in one patient and Ross operation was performed in one case. Isolated supracoronary graft replacement was performed in eight patients. RESULTS: Two patients died during hospitalization: a 10-year old girl developed respiratory failure on the 2nd postoperative day and autopsy revealed Ehlers-Danlos syndrome with a massive intrapulmonary emphysema. A 14-year-old Marfan patient with severely depressed preoperative LV function died from low cardiac output following composite-graft, mitral and tricuspid valve repair. One patient required aortic valve replacement 7 days after an aortic valve sparing root repair. There was no additional perioperative morbidity. In the long-term, two patients died from rupture of the thoracic aorta, both following minor non-cardiovascular surgical procedures. Both had normal sized descending and abdominal aorta. CONCLUSION: Repair of the aortic root and/or ascending aorta in children and adolescent patients can be performed with acceptable early and late results. While the presence of severe comorbidity may adversely affect early outcome, long-term survival was mainly determined by rupture of the descending aorta.     

Aortic root replacement in patients with previous heart surgery

OBJECTIVE: The objective was to review the operative risk and outcomes of redo aortic root replacement. PATIENTS AND METHODS: From July 1990 to December 2001, aortic root replacement was performed in 165 patients who had at least one previous cardiac operation. Their mean age was 49 +/- 16 years and 78% were men. Twenty-eight patients had a previous aortic root replacement. The principal indication for surgery was prosthetic aortic valve dysfunction. All the patients had a dilated, calcified, ruptured, or some other abnormality of the aortic root. The follow-up was complete and extended from 0 to 12.5 years, mean of 3.8 years. RESULTS: There were 12 operative (7%) and 20 late deaths (12%). The survival at 8 years was 68%+/- 6%. The principal cause of death was cardiovascular related. Age at increments of 5 years (risk ratio: 1.2; CI: 95%; 1.1 to 1.4) and preoperative New York Heart Association functional class IV (risk ratio: 2.2; CI: 95%: 1.1 to 4.7) were the only two independent predictors of death. Two patients had a stroke and died; two patients developed three episodes of prosthetic valve endocarditis and died. Three patients were reoperated on because of endocarditis in one, bioprosthetic valve failure in one, and dehiscence of a prosthetic mitral valve in one. The freedom from reoperation at 8 years was 93%+/- 5%. CONCLUSIONS: Redo aortic root replacement can be done with low operative mortality in elective patients and the risk increases in those who need emergent surgery and are older. The long-term results are satisfactory and similar to those for patients who have aortic root replacement for the first time.     

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.     

Sixteen-year experience with aortic root replacement. Results of 172 operations.

During a 16-year interval ending in October 1990, 168 patients underwent 172 aortic root replacements. Thirty patients (18%) had Marfan syndrome. Annuloaortic ectasia (81 patients) and aortic dissection (63 patients) were the principal indications for operation. Twenty-seven patients (16%) had previous operations on the ascending aorta or aortic valve. The hospital mortality rate was 5% and the duration of cardiopulmonary bypass was the only significant independent predictor of early death (p = 0.017). Major modifications in technique were made in 1981, when the inclusion/wrap technique employing a composite graft (used in the first 105 procedures) was abandoned in favor of an open technique (used in 51 procedures), and in 1988, when aortic allografts and pulmonary autografts were introduced for selected conditions (reoperations, dissection, endocarditis, isolated aortic valve disease) in 16 patients. The mean duration of follow-up was 81 months. Forty-six patients were followed for more than 10 years. The actuarial survival rate was 61% at 7 years and 48% at 12 years. No significant difference in survival rate was observed between the patients with annuloaortic ectasia and aortic dissection, or between the inclusion/wrap and open techniques. However the frequency of pseudoaneurysm formation at suture lines and the frequency of reoperations on the ascending aorta and aortic valve were less with the open technique. The actuarial freedom from thromboembolism for the 152 patients with prosthetic valves was 82% at 12 years. One early and one late death occurred among the 16 patients with allograft or autograft root replacement. Anticoagulant therapy was not used in these patients and no thromboembolic episodes occurred in the follow-up period (mean, 7 months). The satisfactory results observed with extended follow-up support the continued use of the composite graft technique as the preferred method of treatment for patients with annuloaortic ectasia, persistent aneurysms of the sinuses of Valsalva following previous operations, and for patients with ascending aortic dissection who require aortic valve replacement. The availability of aortic root allografts and the perfection of techniques for safe implantation of the autologous pulmonary root into the aortic position have broadened the indications for aortic root replacement.     

TECHNIQUES OF REINFORCING THE ASCENDING THORACIC AORTA

Two techniques of reinforcing the ascending thoracic aorta with Dacron vascular prosthetic material are described. Circular reinforcement has been used in patients with fusiform dilatation of the ascending thoracic aorta in whom it was considered that graft replacement was unsuitable, and also in patients with a thin-walled aorta, where reinforcement was thought to be beneficial in preventing dehiscence of an aortic suture line. The techniques are described in two patients who underwent aortic valve replacement and who had aneurysmal dilatation of the ascending thoracic aorta.