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J Thorac Cardiovasc Surg 2003;126:1978-1985
© 2003 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Acute type a aortic dissection complicated by aortic regurgitation: composite valve graft versus separate valve graft versus conservative valve repair

^a Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif, USA

Read at the Twenty-eighth Annual Meeting of The Western Thoracic Surgical Association, Big Sky, Mont, June 19-22, 2002.

Received for publication June 30, 2002; revisions received June 1, 2003; accepted for publication July 7, 2003.

^* Address for reprints: D. Craig Miller, MD, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247, USA
dcm{at}stanford.edu

OBJECTIVE: To clarify the merits of various surgical approaches, we studied the outcome after composite valve graft versus separate valve and graft replacement versus conservative valve treatment with replacement of the ascending aorta in patients with acute type A aortic dissection complicated by aortic regurgitation.

METHODS: Between 1967 and 1999, 123 patients (mean age 56 ± 15 years) underwent composite valve graft replacement (n = 21), separate valve and graft replacement (n = 20), or conservative valve treatment (n = 82 [commissural resuspension in 46]); follow-up averaged 6.5 years (95% complete).

RESULTS: The 30-day, 1-year, and 6-year survival estimates of 85% ± 4%, 79% ± 5%, and 69% ± 5% (±1 standard error of mean), respectively, after conservative valve treatment were similar to 86% ± 8%, 81% ± 9%, and 65% ± 16%, respectively, with composite valve graft replacement and better (but insignificantly so) than 70% ± 10%, 70% ± 10%, and 45% ± 11%, respectively, with separate valve and graft replacement. The 6-year freedom from proximal reoperation was 95% ± 3%, 89% ± 10%, and 100% in conservative valve graft, separate valve and graft, and composite valve graft subgroups, respectively (P = not significant). Cox regression multivariable analysis identified that previous sternotomy (hazard ratio [or e^ß] 95% confidence interval 1.4-10.9, P = .006), hypertension (0.99-2.9, P = .05), cardiac tamponade (1.1-4.0, P = .03), and stroke (1.7-7.0, P = .001) increased the hazard of death. No factors predicting a higher likelihood of late proximal reoperation were identified.

CONCLUSIONS: In patients with acute type A aortic dissection and aortic regurgitation, there was no significant difference in overall survival or reoperation rates among these surgical approaches. We try to save the valve whenever possible unless the aortic root is pathologically dilated (eg, Marfan syndrome or annuloaortic ectasia) or destroyed by the dissection process, when composite valve graft or valve-sparing aortic root replacement is indicated.

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