Between September, 1974, and December, 1985, 127 patients had replacement of the ascending aorta and aortic valve with a composite graft. Annuloaortic ectasia was the most common indication for operation (69 patients), followed by aortic dissection (51 patients). Twenty-four patients (19%) had the Marfan syndrome. Hospital mortality was 4.7%. Emergent operation for acute dissection was the only independent predictor of hospital death (p = 0.03). Reoperation for postoperative hemorrhage was required in 15 patients (11.8%) and for prosthesis-related complications (pseudoaneurysm, prosthetic endocarditis, technical problems, and valve thrombosis) in 16 patients (12.6%). Since we adopted a technique of preclotting the prosthesis with whole blood or albumin plus autoclaving and abandoned the inclusion technique, the reoperation rate has declined substantially. At 5 years, the actuarial freedom from reoperation for any reason on the ascending aorta or aortic valve for the 24 patients in whom this modification was used was 90% and for the remaining 103 patients, 73% (p = 0.17). No reoperations for pseudoaneurysms or technical problems were required in these 24 patients, whereas 10 reoperations for these complications were necessary in the other patients. The mean duration of follow-up was 54 months. The actuarial survival rate at 7 years for the entire group was 65%; for the patients with annuloaortic ectasia, 70%; for those with aortic dissection, 61%; for the patients with the Marfan syndrome, 57%. Actuarial freedom from operation on the remainder of the aorta at 7 years was 89%, but it was 78% for the subgroup with the Marfan syndrome. The satisfactory results with extended follow-up support the continued use of the composite graft technique as the preferred method of treatment for patients with annuloaortic ectasia or recurrent aneurysms of the sinuses of Valsalva and for patients with aortic dissection who require aortic valve replacement.