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

摘要

? 2023 The Society of Thoracic SurgeonsBackground: 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.