Current treatment of acute dissections of the ascending aorta

In 1977, the authors introduced the gelatin resorsin formol glue for emergency surgery of dissection of the ascending aorta (Stanford Type A). This special issue devoted to surgery of the thoracic aorta gives them the opportunity of summarising the different techniques of replacing the ascending aorta, underlying the procedures available for reinforcing the sutures. The value of the gelatin resorcin formol glue extensively described and the authors then analyse the principles and methods of treating aortic insufficiency and of the extension of replacement of the aorta to the aortic arch. Based on these techniques, the authors report their experience over a period of 20 years. Between January 1977 and July 1997, 193 patients (139 men and 54 women) aged 15 to 79 (average 53 years) were operated for acute dissection of the ascending aorta. All the operations were undertaken as an emergency and 84% within 4 hours of arrival at the hospital. Twenty-eight patients had typical Marfan's syndrome. The ascending aorta was replaced in all cases and the aortic stumps reinforced with GRF glue in 99% of them. Forty-three patients underwent aortic valve replacement either separately (5 patients: 2.5%) or with a valved tube (35 patients: 19.5%). More recently, 3 patients underwent complete replacement of the ascending aorta with reimplantation of the coronary arteries and conservation of the natural valve. In view of the localisation or the extension of the intimal tear, complete replacement of the ascending aorta was extended to the aortic arch in 58 patients (30%). The global hospital mortality was 21% (23% in patients undergoing replacement of the aortic arch and 20.3% in patients undergoing replacement of the ascending aorta with or without aortic valve replacement N.S.). The patients were followed up for 2 months to 19 years (average 85 +/- 66 months). During the observation period, 23 patients (15%) were reoperated and underwent 29 reoperations. Six patients died during reoperation. Late mortality was observed in 36 patients (23.7%) giving a global actuarial survival (Kaplan-Meier-95% confidence interval) was 96.5% 87.6%, 80.9%, 66.4% at 1, 5, 10 and 15 years respectively. The clinical status of the 116 survivors is satisfactory. Eighty-two patients (71%) are in functional Classes I or II. Surgery of acute dissection of the ascending aorta remains difficult and associated with high mortality and morbidity. The use of GRF glue has significantly improved the immediate results and has made extension of surgery to sections of the aorta otherwise inaccessible, a reality. Nevertheless, the patients should be followed up indefinitely by regular non-invasive methods and maintained on betablocker therapy.