Surgical management of ascending and aortic arch disease: refined techniques with improved results.

BACKGROUND

Treatment of aneurysms of the ascending aorta, arch aorta, or both is surgically challenging and has traditionally carried a high hospital mortality rate. The use of refined operative techniques, including improved grafts, enhanced myocardial protection, retrograde cerebral perfusion with circulatory arrest, transesophageal echocardiography, and control of hematologic factors, has resulted in reduced hospital mortality rates.

METHODS

We conducted a retrospective analysis of records of 117 consecutive patients who underwent 118 procedures between March 1987 and September 1997, for graft replacement of the ascending or transverse aortic arch with or without aortic valve reconstruction or replacement. There were 67 men (57.3%) and 50 women (42.7%). The mean age was 61.4 years (range, 16 to 81 years). Aortic abnormalities were medial degeneration in 59 patients (50.0%), dissection in 28 patients (23.7%), atherosclerosis in 16 patients (13.6%), Marfan's syndrome in 8 patients (6.8%), and other in 7 patients (5.9%).

RESULTS

The ascending aorta alone was replaced in 58 patients (49.2%), ascending and arch aorta in 56 patients (47.5%), and isolated arch aorta in 4 patients (3.4%). Twenty-six patients (22.0%) required aortic valve reconstruction, 17 patients (14.4%) had separate aortic valve replacement, and 37 patients (31.4%) received a valve conduit. Overall hospital mortality rate was 3.4% (4 of 117 patients). Postoperative complications included myocardial infarction in 3 patients (2.5%), stroke in 7 patients (5.9%), pulmonary insufficiency in 22 patients (18.6%), renal insufficiency in 4 patients (3.4%), and reoperation for bleeding in 8 patients (6.8%). There were no deep sternal wound infections. Follow-up was completed for 112 (99.1%) of 113 survivors and ranged from 1 month to 10.6 years (mean, 39.5 months). Actuarial survival for patients discharged from the hospital was 87.9%+/-3.7% (standard error of the mean) at 3 years and 79.7%+/-5.8% at 6 years.

CONCLUSIONS

Graft replacement of the ascending and transverse aortic arch, although technically demanding, can be performed with low hospital mortality and morbidity rates.