Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency. A selective approach.

The selection of an appropriate surgical technique for repair of aneurysm of the ascending thoracic aorta with associated aortic insufficiency is unsettled. Placement of a supracoronary graft (separate G/V) is a compromise if the coronary ostia are displaced cephalad by the aneurysm, whereas insertion of a valved conduit is difficult and unnecessary if the coronary ostia are normally placed. From June, 1979, to December, 1982, 140 patients underwent repair of ascending aortic aneurysm with aortic valve replacement (AVR). Mean age was 46 years. Annuloaortic ectasia was the most common indication for repair (71/140, 50.7%), followed by acute and chronic dissection (47/140, 33.6%). Twelve patients had undergone previous operations on the ascending aorta or aortic valve, including five separate G/V repairs. Eighty-nine patients (63.6%) underwent composite replacement with coronary reimplantation and 51 (36.4%) had separate G/V repair or primary repair of the aneurysm. Cardiopulmonary bypass methods, times, and postoperative complications were comparable between the two groups. Hospital mortality for the whole series was 7.9% (11/140), with 5.6% (5/89) in patients having conduit replacements and 13.7% (7/51) in patients having separate G/V repair. Mortality correlated with separate G/V repair in patients with annuloaortic ectasia (p = 0.005) and with conduit repair of atherosclerotic aneurysms (p = 0.05). Among 90 patients followed up a total of 1,778 patient-months, there were seven late deaths: three new dissections, two sudden deaths without autopsy, and two patients with chronic congestive heart failure unimproved or made worse with the operation. Notably, no patient has required reoperation for conduit malfunction or has required repair of aneurysm or paravalvular leak below a supracoronary graft. Clinical anatomic assessment at operation should determine the technique of repair employed, based on the degree of displacement of the coronary ostia relative to the aortic anulus.