Conservative treatment of the aortic root in acute type a dissection

Objective: In acute type A dissection long-term results of conservative aor tic root surgery were compared with the outcome of primary valve and/or roo t replacement. Methods: Between 1985 and 1995, 199 patients (mean age 59 ye ars, 154 men) were operated on. The aortic root was involved in the dissect ion process and valve incompetence of varying degree was present without ex ception. Replacement of a proximal aortic segment was standard procedure in all patients. The aortic valve was preserved in 126 patients: commissural suture resuspension (12 patients), root reconstruction with GRF-glue (gelat ine-resorcin-formaldehyde/glutaraldehyde-glue) (114 patients). Valve replac ement was performed in 73 patients (50 composite grafts, 23 valve prosthese s with separate supracoronary grafts). Preoperative risk factors (valve rep lacement vs. preservation): coronary artery disease (11 vs. 8%, NS), tampon ade (18 vs. 17%, NS), unstable hemodynamics (22 vs. 15%, NS), renal failure (4 vs. 6%, NS), neurologic disorder(19 vs. 32%, NS). Results: The overall early mortality was 23.6% (47/199 patients) and increased after commissural suture resuspension compared with GRF-glue reconstruction (P = NS). Parame ters of the early postoperative period did not differ between conservative treatment and root/valve replacement: low cardiac output, 34 versus 38% (P = NS); myocardial infarction, 10 versus 11% (P = NS); hemorrhage, 25 versus 23% (P = NS); duration of intensive care (P = NS). Survival was 61% after 8 years without difference between the two principal treatment groups (P = NS) and between the two conservative subgroups (P = NS). At 2 years, GRF-gl ue reconstruction had an increased freedom from reoperation on the aortic r oot (92 vs. 70%, P = 0.0253) and event free survival (77 vs. 41%, P = 0.022 4) compared with suture resuspension. Commissural suture resuspension was a n independent, significant predictor for reoperation (P = 0.0221, relative risk = 4.7130). Conclusion: Surgery for acute type A dissection still carri es a considerable early risk. Preservation of the aortic root is safe in th e absence of Marfan or annuloaortic ectasia, but a certain incidence of reo perations on the aortic valve and the aortic root has to be accepted. Root reconstruction using GRF-glue is the method of choice and is superior to su ture resuspension, with a significantly better reoperation-free and event-f ree survival. (C) 1999 Elsevier Science B.V, All rights reserved.