Composite valve graft versus separate aortic valve and ascending aortic replacement: Is there still a role for the separate procedure?

Background: To ascertain if operative technique has any hearing on outcome, the surgical results after aortic root replacement using either a composite valve graft (CVG) or a separate graft and valve (GV) were analyzed. Methods and Results: Three hundred and ninety consecutive, nonrandomized patients treated for aortic valve disease and ascending aortic aneurysm (n=278) or type A dissection (n=112 [45 acute]) between 1965 and 1995 were analyzed retrospectively. One hundred and thirty-five patients received a CVG, and 255 had separate GV replacement. Mean age was 52±16 years (±1 SD). Eighty-two patients (44% of the CVG group) had the Marfan syndrome (MFS). Follow-up (96% complete) totaled 2247 patient-years and extended to 27 years. The operative mortality rate was 10±3% (±70% confidence limits) for patients receiving a CVG and 15±2% for GV replacement (P=NS). The 15-year actuarial survival estimate was higher for the CVG group (53±14% [±SEM] versus 36±4%, P=.037). Seven patients in the CVG group required reoperation on the aortic valve or ascending aorta, as did 49 in the GV group. The probabilities of freedom from reoperation on the aortic root were 82±9% and 75±4% at 10 years for the CVG and GV group (P=NS). Thirty variables were analyzed in a multivariate model: pulmonary disease, higher New York Heart Association functional class, and longer cardiopulmonary bypass time were linked with higher operative mortality risk; older age, emergency operation, coronary artery disease, and liver dysfunction were independent determinants of late death. Younger age and use of a bioprosthesis were predictors of late reoperation. Type of procedure (GV versus CVG) was not a significant predictor of any outcome variable. Conclusions: The long-term results after CVG or GV were similar, which reflects proper patient selection. Use of a composite valve graft theoretically confers more protection against recurrent aortic root aneurysm, and, unless one opts for a valve-sparing aortic root replacement procedure, is most appropriate for younger patients, those with the MFS (including acute dissections), and others with marked pathological involvement of the sinuses. On the other hand, use of a separate GV should not he abandoned; in carefully selected patients (and if properly performed, eg, excision of the sinuses), GV also provides satisfactory results.