Introduction
Acute type A aortic dissection (ATAAD), is a surgical emergency with the potential for catastrophic consequences because of any delays in intervention, with a lethality rate of 1-2% per hour following symptom onset1. Annual incidences reported from 2.5-6 per 100,000 patient-years2, reaching as high as 8.7 per 100,000 patient-years likely resulting from our ageing population as a leading contributor.3 ATAAD, a disaster where the repair process is never clear nor obvious, with every second crucial to saving the patient’s life.
In cases of ATAAD, often there is the involvement of the aortic root potentially resultant of extension of the primary tear. It is possible that root pathologies independent of the primary tear are discovered and may result in concomitant treatment. Surgical intervention on the aortic root remains controversial and debatable. 4,5,6,7
Acute aortic dissection repair can necessitate a variety of operations, from simple replacement of the ascending aorta to aortic root replacement or a version of total arch replacement. There are differing opinions regarding what constitutes the “appropriate” repair of the acutely dissected aorta, 4-8, 13-27 a tear tailored approach is a trend that we normally follow; however, this is not generalizable across many different centers.
During the surgical repair, when it comes down to the fate of the aortic root there remains a large amount of controversy in the literature.4,5,6,7 The following remains unanswered :
  1. Should a surgeon perform the Bentall procedure, radically replacing the complete root with all its sinuses, or conservatively repair the primary damage and preserve the native root structures?
  2. What are the implications of these decisions on mortality, and the risks of re-operation?
Another rather ambiguous matter remains which is decision-making framework on aortic root intervention. This is rather scattered with different complexities seen in ATAAD, hence, no quantitative assessment exits. The implementation of optimum treatment strategies from the initial diagnosis to complete repair can improve the prognostic outcome, from the mortality of 90% without intervention to upwards of a 70% chance of survival.8 Henceforth, thoughtful decision making process, operative planning, meticulous surgical technique, and intrinsic understanding of hypothermic circulatory arrest and central nervous system preservation are all sought for optimum outcomes.