Decision process for preserving the root
A potential confounding factor favouring better outcomes in AAG patients may be the surgeon’s preference for root replacement in cases involving more extensive disease at presentation. Our experience suggests, poor aortic tissue quality, lack of aortic valve leaflet integrity and a larger aortic root are used by surgeons as subjective variables to favour replacement of the aortic root. These characteristics, which are not reflected in operative risk assessment, may have contributed to higher operative mortality in this cohort. A greater emphasis on individual surgeon familiarity with the chosen operative strategy is necessary, compared to elective cardiac surgery procedures, given the variability of ATAAD presentation and emergency nature of surgery for type A aortic dissection. In this series, the higher mortality in the ARR cohort was not reflected in increased incidence of postoperative complications.
A well-established concern with preservation of the native aortic valve following ATAAD is a possible increased risk of subsequent reintervention on the native aortic root or valve[10]. However, several surgical centres have been able to achieve low rates of surgical reintervention during long term follow up. Von. Segesser et al. and Mazzucotelli demonstrated freedom from reoperation of 91% and 80% respectively in a case series of patients undergoing valve resuspension procedures for ATAAD [13][3]. The incidence of reintervention on the aortic root or valve in this study was similarly low in both cohorts. The present study also found the dimensions of the aortic root to be realtively stable following resuspension of the native aortic valve. Only 2 patients were observed to have significant dilation of the aortic root during follow-up, both of whom underwent reintervention.