Surgery of acute type A dissection: what have we learned during the past 25 years?

Every acute dissection involving the ascending aorta (Stanford type A) must undergo emergency surgical repair. However, the surgical techniques must vary according to the clinical presentation of the patients or the anatomical patterns observed. Furthermore, surgery is generally difficult because of the poor condition of the aortic tissues. To reduce those difficulties many technical artifacts have been described. In 1977, we proposed the use of gelatin-resorcin-formalin (GRF) biological glue to reinforce the suture areas. From January 1977 to July 1999, 212 patients (pts) (152 males and 60 females) aged from 15 to 80 years (mean age: 54 +/- 11 years) underwent an emergency operation for type A aortic dissection. One-hundred-seventy-eight pts (84%) were operated on within 4 hours after being referred to the hospital. Twenty-eight pts (13.2%) had Marfan's syndrome. In 44 patients (20.7%), the aortic valve was replaced either independently (6 cases--2.8%) or by means of a composite graft (38 cases--17.9%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 61 pts (28.7%). Hospital mortality amounts to 21.6% (46 pts), 25% in pts with arch replacement and 19.4% in pts without arch replacement (n.s). Analysis of hospital mortality demonstrates that the main causes of death were cardiac tamponade, neurologic disorders and visceral malperfusion. One-hundred-sixty-six pts were discharged and surveyed from 5 months to 22 years postoperatively (mean follow-up: 85 +/- 66 months). During this period of time, 25 pts (15%) had to be reoperated for a total of 33 reoperations. Seven pts (28%) died at reoperation. Using univariate analysis, the presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were determinant risk factors for reoperation. Emergency (p < 0.01) and thoraco-abdominal replacement (p < 0.04) were determinant riskfactors for death at reoperation. The freedom from reoperation (Kaplan-Meier, CI: 95%) is 96% (90-98), 87% (79-92), 80% (70-88), 66% (51-78) at 1, 5, 10 and 15 years respectively. A total of 39 pts (24.3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were determinant risk factors of late mortality. The late survival rate (K-M. C.I.: 95%), including hospital mortality, is 71% (64-77), 66% (58-73), 56% (47-64), 46% (36-56), 37% (28-44) at 1, 10, 15 and 20 years, respectively. From our experience extending over more than 23 years, GRF glue has proved to be extremely useful, making the procedure much easier and safer. Nevertheless, many factors are of importance in the pre-, intra- and postoperative management of the patients. Cardiac tamponade and visceral malperfusion must be properly diagnosed and treated. During aortic repair, the main intimal tear must be resected. The transverse arch must be checked and replaced whenever necessary. The aortic valve should be preserved whenever possible. During CPB, perfusing the aorta in the regular antegrade manner seems to dramatically reduce the rate of malperfusion. The quality of the first emergency operation seems to have a major influence on the late results, especially concerning the rate of late reoperations and aortic ruptures. However, those late results depend also on the patient's basic condition, particularly in Marfan patients.

Surgery of acute type A dissection: what have we learned during the past 25 years?

Every acute dissection involving the ascending aorta (Stanford type A) must undergo emergency sugical repair. However, the surgical techniques must vary according to the clinical presentation of the patients or the anatomical patterns observed. Furthermore, surgery is generally difficult because of the poor condition of the aortic tissues. To reduce those difficulties many technical artifacts have been described. In 1977, we proposed the use of gelatin-resorcin-formalin (GRF) biological glue to reinforce the suture areas.From January 1977 to July 1999, 212 patients (pts) (152 males and 60 females) aged from 15 to 80 years (mean age: 54±11 years) underwent an emergency operation for type A aortic dissection. One-hundred-seventy-eight pts (84%) were operated on within 4 hours after being referred to the hospital. Twenty-eight pts (13.2%) had Marfan's syndrome. In 44 patients (20.7%), the aortic valve was replaced either independently (6 cases - 2.8%) or by means of a composite graft (38 cases - 17.9%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 61 pts (28.7%).Hospital mortality amounts to 21.6% (46 pts), 25% in pts with arch replacement and 19.4% in pts without arch replacement (n. s.). Analysis of hospital mortality demonstrates that the main causes of death were cardiac tamponade, neurologic disorders and visceral malperfusion.One-hundred-sixty-six pts were discharged and surveyed from 5 months to 22 years postoperatively (mean follow-up: 85±66 months). During this period of time, 25 pts (15%) had to be reoperated for a total of 33 reoperations. Seven pts (28%) died at reoperation. Using univariate analysis, the presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were determinant risk factors for reoperation. Emergency (p < 0.01) and thoraco-abdominal replacement (p < 0.04) were determinant riskfactors for death at reoperation. The freedom from reoperation (Kaplan-Meier, CI: 95%) is 96% (90-98), 87% (79-92), 80% (70-88), 66% (51-78) at 1, 5, 10 and 15 years respectively.A total of 39 pts (24,3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were determinant risk factors of late mortality. The late survival rate (k-M. C.I.: 95%), including hospital mortality, is 71% (64-77), 66% (58-73), 56% (47-64), 46% (36-56), 37% (28-44) at 1, 10, 15 and 20 years, respectively.From our experience extending over more than 23 years, GRF glue has proved to be extremely useful, making the procedure much easier and safer. Nevertheless, many factors are of importance in the pre-, intra- and postoperative management of the patients. Cardiac tamponade and visceral malperfusion must be properly diagnosed and treated. During aortic repair, the main intimal tear must be resected. The transverse arch must be checked and replaced whenever necessary. The aortic valve should be preserved whenever possible. During CPB, perfusing the aorta in the regular antegrade manner seems to dramatically reduce the rate of malperfusion. The quality of the first emergency operation seems to have a major influence on the late results, especially concerning the rate of late reoperations and aortic ruptures. However, those late results depend also on the patient's basic condition, particularly in Marfan patients.

Antegrade cerebral perfusion with cold blood: a 13-year experience.

BACKGROUND: In 1986 we introduced the technique of antegrade selective perfusion of the brain with cold blood during surgery of the aortic arch. METHODS: Between January 1984 and March 1998, 171 patients (118 males and 53 females) aged 25 to 83 years (mean 56.5 +/- 17), underwent replacement of the transverse aortic arch with the aid of cold blood antegrade selective perfusion. One hundred twenty two patients (71.3%) with chronic lesions were operated on electively; 49 patients (28.6%) were operated on urgently for acute aortic dissection (42 patients) or for a ruptured chronic aneurysm (7 patients). Fifty-one patients (29.8%) had previously undergone a surgical procedure on the thoracic aorta. Mean duration of cardiopulmonary bypass was 121 minutes (range: 65-248); mean duration of cerebral perfusion was 60 minutes (range: 15-90), and mean duration of systemic circulatory arrest circuit was 32 minutes (range: 10-57). The electroencephalogram, routinely recorded, showed disappearance of electrical activity in a mean of 9 minutes (range: 3-16) initial return of electrical activity after a mean of 12 minutes (range: 1-35) and normalization in a mean time of 66 minutes. RESULTS: All patients but 7 (4%) showed signs of normal awakening within 8 hours postoperatively. Six patients (3.5%) had fatal neurologic complications, and 16 patients (9.3%) had a non-fatal neurologic complications. Twenty-nine patients (16.9%) died during the postoperative hospital course. There was a significant difference between patients aged less than 60 years (9%) and patients older than 60 years (mortality rate 26.4%, p < 0.02). There was also a significant difference between patients undergoing an isolated replacement of the arch, and those in whom the replacement was extended to the descending aorta in whom mortality was 36.4% (chi2, p < 0.02). Lesion and gender had no significant influence on the outcome of the patients, nor had the duration of cardiopulmonary bypass, circulatory arrest, and cerebral perfusion. In particular, no correlation could be established between the duration of cerebral perfusion and the occurrence of neurologic complications. CONCLUSION: The clinical results obtained throughout this experience have demonstrated that selective antegrade cerebral perfusion with cold blood provides excellent protection during surgery of the transverse aortic arch. In addition, it avoids the use of deep hypothermia and prolonged cardiopulmonary bypass and does not limit the time allowed to perform the aortic repair. In our opinion it is the technique of choice, especially in frail patients or those requiring a long and difficult procedure.

Surgery for acute type A aortic dissection: the Hopital Foch experience (1977-1998).

BACKGROUND: In 1977, we proposed the use of gelatin-resorcinol-formol (GRF) biological glue during surgery for acute type A aortic dissection. METHODS: From January 1977 to March 1998, 204 patients (146 men and 58 women) aged from 15 to 79 years (mean 54 +/- 11) underwent emergency operation for type A aortic dissection in our institution. One hundred sixty-five patients (84%) were operated on within 48 h after the onset of symptoms. Twenty-eight patients (13.7%) had Marfan's syndrome. In 43 patients (23%), the aortic valve was replaced either independently (6, 3%) or by means of a composite graft (37, 18.1%). Because of the location of the intimal tear, aortic replacement included the transverse arch in 60 patients (29.4%). RESULTS: Hospital mortality was 21% (39 patients): 25% in patients with arch replacement and 19.4% in patients without arch replacement (ns). One hundred sixty-one patients were discharged and followed from 2 months to 21 years postoperatively (mean 85 +/- 66 months). During this interval, 25 patients (15.5%) required reoperation for a total of 33 reoperations. Seven patients (28%) died at reoperation. Upon univariate analysis, presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were risk factors for reoperation. Emergency operation (p < 0.01) and thoracoabdominal replacement (p < 0.04) were risk factors for death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, confidence interval 95%) is 96.1% (90.9%-98.2%) at 1 year, 87.6% (79.8%-92.7%) at 5 years, 80.9% (70.8%-88.1%) at 10 years, and 66.4% (51.1%-78.9%) at 15 years. A total of 39 patients (24.3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were risk factors for late mortality. The actuarial late survival including hospital mortality is 71.5% (64.3%-77.8%) at 1 year, 66% (58.3%-73%) at 5 years, 56.4% (47.7%-64.7%) at 10 years, and 46.3% (36.4%-56.5%) at 15 years. CONCLUSIONS: The GRF glue has proven extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. As a result of this operative improvement, the use of the GRF glue seems to have had a beneficial influence on late results, but these also depend upon the patient's basic condition.

Current practice in Marfan's syndrome and annulo-aortic ectasia: aortic root replacement with a composite graft over a twenty-year period.

BACKGROUND: From October 1973 to December 1995, 251 patients (204 male, 47 female) aged from 10 to 75 years (mean: 46.6 +/- 15) underwent an ascending aortic replacement with a composite graft for: dystrophic aneurysm (AN), 168 cases (66.9%); chronic dissection (CD), 36 cases (14%); and type A acute dissection (AD), 48 cases (19.1%). Fifty-one patients (20.3%) suffered from Marfan's disease (25 AN, 17 AD, 9 CD). Thirty-seven patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 31 patients (12.3%). A mechanical valve was used in 233 patients (92.8%). The classic "Bentall" technique was used in 87 patients (34.6%), the "button" technique in 121 patients (48.2%), the "Cabrol" technique in 26 patients (10.3%) and a "mixed" technique in 17 patients (6.2%). RESULTS: The hospital mortality accounts for 7.2% (18 out of 251) (AN: 4 out of 68, 2.3%, CD: 4 out of 36, 11.1%, AD: 9 out of 48, 18.7%). When emergencies are considered, the hospital mortality is 12 out of 54 (22.2%) versus 6 out of 197 (3%) in elective procedures. The predictors of hospital death were emergency, AD (p < 0.03) and arch replacement (p < 0.02). Mean follow up is 38 +/- 15 months (4-262). The overall long term survival rate is (Kaplan Meïer): 92 +/- 6% at one year, 77.9% +/- 9% at 5 years, 67.7 +/- 12% at 10 years, and 61.3 +/- 15% at 12 years. The 10-year survival rate is significantly higher in patients with AN (93 +/- 6%) than in patients with AD (61.6 +/- 17%) (p < 0.01). The late survival rate is also significantly higher after the "button" (93.8 +/- 5%) or Bentall's reimplantation (88.7 +/- 6%, 83.8 +/- 9%, and 76.6 +/- 12%) than after the "Cabrol" procedure (80 +/- 18%, 63 +/- 21% and 58 +/- 35%) at 1, 5, and 8 years, respectively. CONCLUSION: Ascending aortic replacement with a composite graft is a safe procedure, especially when performed electively in patients with dystrophic aneurysm or Marfan's disease. The technique of coronary reimplantation has a significant influence of the long-term results, with the reimplantation of choice being the "button" technique. The "Cabrol" technique must be used when the "button" or the "Bentall" reimplantation is not feasible.

The proper use of glue: a 20-year experience with the GRF glue in acute aortic dissection.

BACKGROUND: In 1977, the use of Gelatine-Resorcine-Formaline (GRF) biological glue during surgery of acute Type A aortic dissection was proposed. The present study retrospectively analyzes the late results obtained with this adjunct in an experience extending over a twenty-year period of time. PATIENTS AND METHODS: From January 1977 to March 1996, 171 patients (124 males and 47 females) aged from 15-79 years (mean age: 53 +/- 14 years) underwent an emergency operation for type A aortic dissection in our institution. All patients suffered from acute type A dissection and 144 (84%) were operated on within 48 hours after the onset of symptoms. Twenty-six patients (15.2%) had Marfan's syndrome. The ascending aorta was replaced in all patients and the aortic stumps were reinforced with the GRF glue. In 39 patients (23%), the aortic valve was replaced either independently (5 cases, 3%) or by means of a composite graft (34 cases, 19.8%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 58 patients (33.9%). RESULTS: Hospital mortality amounts to 21% (36 patients), 22.8% in patients with arch replacement and 21.1% in patients without arch replacement (n.s). One hundred thirty-five patients were discharged and surveyed from 2 months to 19 years postoperatively (cumulative follow-up: 856 patients/years. Mean follow-up: 79 +/- 66 months). During this period of time, 22 patients (16.1%) had to be reoperated on for a total of 28 reoperations. Six of those (27.2%) died at reoperation. At univariate analysis, presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were determinant risk factors for reoperation. Emergency (p < 0.01) and thoracoabdominal replacement (p < 0.04) were determinant risk factors of death at reoperation. The acturial freedom from reoperation (Kaplan-Meier, CI: 95%) is: 96.08% (90.9-98.2), 87.6% (79.8-92.7), 80.9% (70.8-86.1), 66.4% (51.1-78.9) at 1, 5, 10, and 15 years respectively. A total of 36 patients (27.7%) died during follow-up. Presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), cardiac failure (p < 0.05) were determinant risk factors of late mortality. The actuarial late survival rate (K-M. C.I.: 95%), including hospital mortality, is: 71.5% (64.3-77.8), 66% (58.3-73), 56.4% (47.7-64.7), 46.3% (36.4-56.5) at 1, 10 and 15 years. CONCLUSIONS: The GRF glue has proved to be extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. Through this operative improvement, the use of the GRF glue seems to have a beneficial influence on the late results which however, depend mainly on the patient's basic condition.

Aortic root replacement with a composite graft. Factors influencing immediate and long-term results.

From April 73 to June 94, 203 patients (167 men, 36 women) aged from 10 to 74 years (mean: 44.8 +/- 15) underwent ascending aortic replacement with composite graft for: dystrophic aneurysm (AN) (130 cases, 64.5%), chronic dissection (CD) (35 cases, 17.2%), type A acute dissection (AD) (38 cases, 18.7%). Forty-six patients (22.6%) suffered from Marfan syndrome (24 AN, 13 AD, 9 CD). Thirty patients (14.7%) had undergone a previous cardiac or aortic operation. The ascending aortic replacement was extended to the transverse arch in 28 patients (13.7%). A mechanical valve was used in 193 cases (95%). Since 1986, the ascending aorta has been totally resected and a gelatin-or collagen-coated vascular prosthesis used. The technique of coronary reattachment has varied with time and according to the aortic lesions. The classic "Bentall" technique was used in 87 patients (43%), the "button" technique in 74 (36%), the "Cabrol" technique in 26 (13%) and a "mixed" technique in 16 cases (8%). The hospital mortality rate was 7.3% (15/203) (AN: 2.3%, CD: 11.4%, AD: 21%). The only predictors of hospital death were emergency AD (P < 0.03) and arch replacement (P < 0.02). Mean follow-up was 46 +/- 10 months (2-246). The overall long-term survival rate was (Kaplan Meier) 89 +/- 6% at 1 year, 77.9 +/- 9% at 5 years, 67.7 +/- 12% at 10 years and 61.3 +/- 15% at 12 years. The 10-year survival rate is significantly higher in patients with AN (77.8 +/- 11%) than in those with AD (61.6 +/- 17%) (log. rank: P < 0.01). The late survival rate is also significantly higher after the "button" or Bentall reimplantation than after the "Cabrol" or "mixed" methods (90 +/- 5% in the "button" group and 88.7 +/- 6%, 83.8 +/- 9% and 76.6 +/- 12% in the "Bentall" group vs 80 +/- 18%, 63 +/- 21% and 58 +/- 35% in the "Cabrol" group at 1, 5 and 8 years, respectively). In conclusion, ascending aortic replacement with a composite graft is a safe procedure especially when performed electively in patients with dystrophic aneurysm or Marfan syndrome. The technique of coronary reimplantation has a significant influence on the long-term results. The reimplantation of choice is the "button" technique, especially in the presence of a fragile aortic wall (AD). The "Cabrol" technique must be used when the "button" or the "Bentall" reimplantation is not feasible, for instance during redo procedures.

Late reoperations in patients with aortic dissection.

Aortic dissection is an evolving process that may require one or several reoperations after the initial emergency repair. From January 1977 to September 1993, 148 patients underwent emergency surgery for type A acute aortic dissection. The replacement of the ascending aorta was extended to include the transverse arch in 43 patients (29%). One hundred fifteen patients (78%) survived surgery. During the same period, 37 patients required reoperation once (28), twice (7), or three times (2), for a total of 48 reoperations. Twenty-one patients had undergone initial repair in our institution; 16 patients had been operated on elsewhere. Reoperation was indicated for: aortic valve disease (4); a new dissecting process (7); threatening aneurysmal evolution of a persisting dissection (34); or false aneurysm (3). The re-do procedure involved: the aortic root and/or ascending aorta in 12 cases (group I); the ascending aorta and the transverse arch in 6 cases (group II); the transverse arch alone in 8 cases (group III); the transverse arch and descending aorta, or the descending aorta alone in 11 cases (group IV); and the thoracoabdominal aorta in 11 cases (group V). Risk factors for reoperation were analyzed in the 115 survivors initially operated on at our institution. Seven of 20 Marfan patients (35%) versus 12 of 95 non-Marfan patients (12.6%) required reoperation (p < 0.02). None of the 31 patients surviving arch replacement at initial repair required a reoperation, versus 21 of 84 (25%) patients surviving replacement limited to the ascending aorta (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic dissection. Prevalence, cause, and results of late reoperations.

From January 1977 to September 1992, 143 patients underwent an emergency operation for type A acute aortic dissection. Because of the location of the intimal tear, the replacement of the ascending aorta was extended to the transverse arch in 42 patients (29.3%). One hundred ten patients (78%) survived the operation. During the same period, 32 patients had to be reoperated on once (n = 24) twice (n = 6), or three times (n = 2) for a total of 42 reoperations. Nineteen patients had had the initial repair in our institution, and 13 had been operated on elsewhere. Reoperation was indicated for aortic valve disease (n = 4), recurring dissection (n = 7) threatening aneurysmal evolution of a persisting dissection (n = 28), or false aneurysm (n = 3). The redo procedure involved the aortic root and/or ascending aorta in 15 cases (group I), the transverse arch alone in 7 cases (group II), the transverse arch and the descending aorta or the descending aorta alone in 10 cases (group III), or the thoracoabdominal aorta in 10 cases (group IV). The risk factors for reoperation have been analyzed in the 110 survivors initially operated on in our institution. Seven of 18 patients with Marfan's syndrome (38.8%) versus 12 of 92 without Marfan's syndrome (13%) were reoperated on (p = 0.023). None of the 30 patients surviving arch replacement at initial repair required a reoperation, versus 19 of 80 (23.7%) patients surviving a replacement limited to the ascending aorta (p = 0.013). The overall mortality rate of reoperation was 21.8% (7/32) with a risk of 16.6% (7/42) at each procedure (group I, 13.3%; group II, 0%; group III, 20%; group IV, 30%). Hospital mortality was influenced by emergency operation (5/10) (p < 0.005) and thoracoabdominal replacement (3/10) (p < 0.035). The late survivals after reoperation are 65.1% +/- 17.6% at 1 year and 55% +/- 19.63% at 5 years (Kaplan-Meier, confidence interval 95%). The late survivals, after the initial repair, of the patients undergoing reoperation are 89.6% +/- 11.0%, 79.3% +/- 14.7%, 53.9% +/- 18.1%, and 35.9% +/- 21.8% at 1, 5, 10, and 12 years, respectively. In conclusion, aortic dissection is an evolving process that may require one or several reoperations after the initial repair. At initial emergency operation, the resection of the entry site, when located on or extending to the transverse arch, has reduced the risk of reoperation, in our experience. Elective reoperation must be considered before the occurrence of complications, especially in patients with Marfan's syndrome.(ABSTRACT TRUNCATED AT 400 WORDS)

Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch.

Profound hypothermia associated with circulatory arrest is the commonest method of cerebral protection during operations on the aortic arch. This technique allows a limited time to perform the aortic repair, however. It also necessitates prolonged cardiopulmonary bypass to rewarm the patient. This may be the cause of coagulation disorders or infection. Selective perfusion of the carotid arteries can also be used. When the perfusion is derived from the main arterial line, however, the repair of the aorta requires that the vessel be crossclamped, and cannot be performed in an "open, bloodless" manner. To avoid the disadvantages of both techniques, we have developed a new technique of cerebral protection. After a regular cardiopulmonary bypass has been established, the carotid arteries are cannulated and perfused with blood cooled at 6 degrees to 12 degrees C, through a separate heat exchanger, while the core temperature is maintained at moderate hypothermia (25 degrees to 28 degrees C, rectal). To perform the "open" distal repair, the cardiopulmonary bypass is discontinued while the carotid perfusion is maintained (250 to 350 ml/min). When the distal repair is completed, cardiopulmonary bypass is resumed and the carotid perfusion is discontinued. Between 1984 and June 1989, 54 patients (mean age 55 years) were operated on with this method (45 elective operations, 9 emergency procedures). Mean duration of cardiopulmonary bypass was 121 minutes (65 to 248), and mean duration of circulatory arrest was 22 minutes (10 to 51). The electroencephalogram, routinely recorded, showed return of the cerebral activity after a mean time of 12 minutes and normal activity after a mean time of 66 minutes. There was no intraoperative death. Hospital mortality rate was 13% (7/54). One death was related to neurologic disorders. All patients but one awakened normally within 8 hours after operation. Two patients (4.3%) experienced a transient neurologic episode (lateral hemianopia) 9 and 11 days postoperatively. There was no hemorrhagic complication (24-hour average blood loss: 840 +/- 540 ml). In our experience the technique of "cold cerebroplegia" has been demonstrated to provide excellent cerebral protection. It requires no prolonged cardiopulmonary bypass and does not limit the time necessary to perform the aortic repair. It may be considered as a safe alternative to profound hypothermia associated with circulatory arrest.

Surgery of aortic stenosis and lesions of the ascending aorta.

Between 1978 and 1986, 442 aortic valvular replacements were performed for chronic calcified aortic stenosis. In 11 patients (2.5%, seven men and four women) replacement of the ascending aorta was associated with the valvular replacement, because of: seven supra-coronary aneurysms, two aneurysms involving the Valsalva sinuses, and two acute dissections of the ascending aorta. The repair of the ascending aorta consisted in inserting: one patch on one Valsalva sinus, seven supra coronary Dacron prostheses, three valved conduits (according to the Bentall technique). One patient died postoperatively (9%).

[Clinical experience with the Saint Jude prosthesis. Results over a period of 7 years]. / Expérience clinique de la prothèse de Saint Jude. Résultats à 7 ans.

Between January, 1979 and December, 1985, 193 Saint Jude medical valves (SJM) were implanted in 165 patients (74 male, 91 female) aged from 14 to 78 years (mean age: 49 years). 101 patients underwent aortic valve replacement, 36 had mitral valve replacement and 21 had multiple valve replacement. Fitting with an SJM prosthesis was a primary emergency operation for 15 patients (9%) and a reoperation for 49 patients (31%). A concomitant surgical procedure was carried out in 39 patients (24%). The overall peri-operative mortality rate was 9% (15 patients), this figure falling to 5% (6/112 patients) when emergency surgery and reoperations are excluded. No patient was lost sight of. Mean follow-up was 37 +/- 3 months (range: 4 to 84 months), for a total duration of 413 years/patient. Five patients died of heart disease during the follow-up period, representing a mortality rate of 1.2% per year/patient. The actual survival rate was calculated as 90% at 1 year and 83% at 7 years. During that period 7 thromboembolic accidents occurred among 5 patients (actual rate: 1.7 accident per 100 years/patient). Two mechanical valve desinsertions requiring reoperation were recorded. Altogether, the actuarial rate of patients without any post-operative complication was 88% at 1 year and 65% at 7 years. Functional improvement was dramatic since 94% of survivors are now in class I or II, whilst 67% of patients were in class III or IV prior to surgery. It may be concluded that the mid-term