Ascending aorta and/or aortic arch reconstruction by composite valve graft (281, 39%), separate valve graft (117, 16%), graft only (256, 36%), and other procedures (63, 9%) was used for aneurysm or dissection caused by trauma (6), infection (20), aortitis (46), dissection (261: acute 72, chronic 189), and medial degeneration (384) in 717 patients during the 9-year period between Jan. 11, 1980, and Jan. 16, 1989. Of these, 150 had 173 previous heart or aortic operations and needed reoperation for progression or recurrence of aneurysm, rupture, valvular insufficiency, aortocutaneous or aorta-heart chamber fistulas, great vein or airway obstruction, and infection. Concurrent distal aneurysmal disease was present or developed in 267 (37%) patients, being most prevalent in patients with arch involvement (211/395, 53%). These patients were treated either simultaneously or later. The ages ranged from 10 to 88 years, median 61. Aneurysm symptoms were mild or absent in 593 (83%) and severe in 124 (17%). The 30-day survival rate was 91%. The independent determinants predictive of 30-day death were increasing age, severe aneurysm symptoms, diabetes, previous proximal aortic operation, need for cardiac support, postoperative tracheostomy, postoperative heart dysfunction, and stroke. Of the 319 patients who had none of the four preoperative factors, 308 (97%) survived. Survival decreased to 74% in those with two or more factors. After a total of 1193 operations, the entire aorta was replaced in 53, near total in 35, total thoracic replacement in 78, and total aorta except arch in 27. Late survival rates (Kaplan-Meier) were 66% and 57% at 5 and 7 years. Independent predictors of death were severe aneurysm symptoms, preoperative angina, extent of proximal replacement, associated residual distal aneurysm, balloon pump, renal dysfunction, cardiac dysfunction, and stroke. Five-year survival rates varied with the incidence of the four preoperative variables and age in a single patient: 78% in 413 patients with up to one variables, 57% in 193 patients with two or three, and 39% in 111 patients with three or four (p less than 0.0001).