Surgical treatment of the ascending aorta. Fourteen years' experience with 83 patients

Abstract

Between December 1972 and December 1986, 83 patients with aneurysmal disease (n = 37) or dissection (n = 46) involving the ascending aorta underwent a variety of operations, including composite value-graft repairs (n = 39), separated replacements of the aortic valve and ascending aorta (n = 18), resuspension and graft replacement of the ascending aorta (n = 9), graft replacement of the ascending aorta only (n = 8), homograft root replacement (n = 3), aortic valve replacement with aortorrhaphy (n = 3), aotorrhaphy alone (n = 2), and use of a sutureless intraluminal prosthesis (n = 1). The inclusion method was used in nine patients. The hospital mortality rate was 10% for patients with annuloaortic ectasia, 21% (70% confidence interval 13% to 30%) for acute dissection, and 18% (70% confidence interval 14% to 22%) for the entire group. Logistic regression analysis showed age and cumulative bypass time to be significant for hospital death. The estimated 5-year survival rates are 69.5% +/- 7.2% and 67.0% +/- 9.0% and 10-year estimates are 34.6% +/- 10.6% and 61.4% +/- 9.8% for dissection and aneurysm, respectively. Patient survival was related to differing pathology and type of operation, and log-rank testing showed no differences at the 5% level. Attrition (17 late deaths) was mostly due to left ventricular dysfunction, myocardial infarction, or aneurysmal disease in ungrafted aorta. Actuarial freedom from thromboembolism in patients with prosthetic valves is 92.0% +/- 4.0% and 83.5% +/- 6.8% at 5 and 10 years. Freedom from all late graft and cardiac complications is 72.5% +/- 9.1% and 48.8% +/- 13.1% at 5 and 10 years for aneurysmal disease and 79.1% +/- 7.3% and 67.3% +/- 9.9% at 5 and 10 years for dissection. Reoperation in nine patients was required for pseudoaneurysms (n = 3), other aortic aneurysms (n = 3), persistent aortic regurgitation (n = 1), and obsolescent valve prosthesis (n = 2). Thus hospital mortality does not seem to be significantly related to the type of operation used for pathologic conditions of the ascending aorta unless cumulative bypass time exceeds about 2 hours. Many nonfatal late complications are associated with a prosthetic valve, but late death is due primarily to cardiac causes and residual disease in other parts of the aorta.