The Aortic Root in Acute Type A Dissection: Repair or Replace?

Background: The effect of an "aggressive" approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored.

Methods: Retrospective analysis was conducted between 1992 and 2020 of a single-center, prospective cohort of consecutive patients aged ≥18 years diagnosed with ATAAD. Patients were divided into 2 groups: aortic root replacement (ARR; prosthetic or valve-sparing root replacement, n = 141) and conservative root approach (CRA; root sparing of partially dissected root, n = 90; and supracoronary ascending replacement in nondissected root, n = 68). Inverse probability weighting was used to compare patients with different preoperative characteristics. Mean follow-up was 5.1 (0-21) years in ARR and 7.1 (0-25) years in CRA.

Results: The frequency of ARR increased over the years, with 19% and 78% of patients undergoing ARR in the earliest and most recent periods, respectively. Early mortality decreased over the years, despite a more aggressive approach, and remained lower in ARR. CRA was associated with a higher hazard of late mortality (hazard ratio, 1.38; 95% CI, 1.12-1.68; P = .001) and reintervention (hazard ratio, 2.08; 95% CI, 1.44-3.56; P = .001). After CRA, new-onset aortic valve insufficiency was a common cause of reintervention.

Conclusions: Over the years, there was a gradual increase in the root replacement approach in ATAAD. Root replacement was associated with better long-term survival and fewer reinterventions compared with the conservative approach, whereas the in-hospital mortality decreased during these years. Hence, aggressive root replacement is safe and may be applied in ATAAD with good long-term clinical results, without increased hospital mortality.