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.