COMPOSITE GRAFT REPLACEMENT OF THE AORTIC ROOT IN ACUTE DISSECTION

Objective: In acute type A dissection the indication for composite gra ft replacement of the aortic root and the optimal implantation techniq ue are a matter of debate. In this study early and late results of roo t replacement in acute dissection are determined and compared with sup racoronary graft replacement. Two implantation techniques (open vs. in clusion) are evaluated. Methods: Between 1985 and 1995, 207 consecutiv e patients (mean age 58 +/- 12 years, 78% men) were operated for acute type A dissection of the aorta. Root replacement in 50 patients (incl usion technique in 34/50 patients with Cabrol shunt in 15/34 patients, open technique in 16/50 patients) was compared with more conservative procedures in 157 patients: supracoronary graft replacement in 143 pa tients (with aortic valve replacement in 23 patients) and local repair without graft interposition in 14 patients. Preoperative risk factors , like hemodynamic instability, renal failure, neurologic disorder and coronary artery disease did not differ in the two treatment groups. R esults: Early results, survival and reoperation-free survival after 5 years were insignificantly better after root replacement; mortality 10 /50 (20%) vs. 38/157 (24%) P = n.s.; hemorrhage 10/50 (20%) vs. 39/157 (25%) P = n.s.; stroke 5/50 (10%) vs. 27/157 (17%) P = n.s.; survival 70 +/- 7% vs. 63 +/- 4%, reoperation free survival 92 +/- 6% vs. 78 /- 5% P = 0.0815). For the open technique, early mortality was 18.8 vs . 20.6%, P = n.s. and reoperation free survival at 5 years was 80.7 vs . 65.2%, P = n.s. Perioperative complications did not differ in the tw o technical groups and a single pseudoaneurysm occurred in the Bentall group. Conclusion: In acute dissection composite graft replacement of the aortic root can be carried out with good early and late results n ot inferior to more conservative procedures. The open technique is the implantation method of choice and the modified Bentall technique is i ndicated in situations with increased risk of bleeding. (C) 1998 Elsev ier Science B.V. All rights reserved.