When should the root be replaced in TAAAD?
It is clear that replacement of the aortic root should be performed if
the aortic root is aneurysmal or extensively destroyed in patients with
TAAAD(10). It has been realized that the classic
teaching of supracomissural repair (SCR) for all patients is
inappropriate due to the documented increase in reoperation rates(11). However, the decrease in reoperation rate
observed following root replacement is associated with an increase in
cardiopulmonary bypass (CPB) time(11). Furthermore, it
is well documented that the increase in CPB time is associated with a
pronounced increase in mortality and morbidity(12,
13). Therefore, multiple investigators studied the risk factors for
reoperation following limited repair in TAAAD to identify a cohort of
patients that would benefit the most from extensive root
repair(14). While the data is mostly retrospective and
single institution, the risk factors identified for reoperations on the
aortic root following SCR include: dilated aortic annulus >
27 mm, the use of glue, Age <60, Marfan syndrome, the number
of sinuses involved, (11, 14-17). At Emory, our policy
is to replace the aortic root if the aortic root diameter is
>4.5 cm, the tear is located in the root, in young
patients, and patients suspected to have connective tissue disease. We
do not perform root replacement in patients with evidence of
malperfusion or clinically unstable patients. We believe that a shorter
CPB time is of paramount importance in TAAAD patients who have complex
clinical presentation.