Surgical treatment of aneurysms of the ascending aorta: early experience with the sinus-shaped composite dacron graft.

This paper reviews the early and late results of 36 operations for aneurysms of the ascending aorta. Cystic medial necrosis was the predominant cause of aneurysm formation (56%), followed by arteriosclerosis (25%), previous aortotomy (11%) and syphilitic aortitis (8%). Dissection was encountered in 42%. The ascending aorta was replaced by a tubular Darcron graft in 26 patients, whereas 10 underwent aneurysmorrhaphy. Additional procedures were aortic valve replacement (27), resuspension of the aortic commissures (4) and coronary ostial implantation into sinus-shaped composite Dacron graft (4). Hospital mortality (0--18 days) was 8/36 patients (22%), but higher with cystic medial necrosis (30%), dissection (33%), duration of ECC greater than 180 minutes (38%), graft replacement (44%), emergency operation (45%) and heart volume greater than 900 ml/m2 BSA (50%). Late mortality (average 3 years) was 29%, but higher with cystic medial necrosis (33%), following aortic valve replacement (36%) and during anticoagulation (47%). Late cumulative survival (average 3 years) was 47% for the entire series, but only 33% in the presence of cystic medial necrosis. The poor overall prognosis for patients with cystic medial degeneration was closely related to a high incidence of fatal anastomotic complications and late deaths from cerebral haemorrhage during anticoagulation. Radical exclusion of the diseased aortic wall and omission of long-term anticoagulation are therefore desirable in order to lower the mortality rate. Surgery concerns the aneurysm per se, the aortic incompetence and the coronary ostia. The sinus-shaped composite graft with a Björk-Shiley prosthesis at its base appears to be a promising device for such a procedure, which should be performed electively, following early diagnosis in order to prevent dissection and emergency operations.