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Management of the aortic root in aortic dissection: Replace or repair?

To the Editor, Management of the aortic root (AR) in acute type A aortic dissection (A‐AAD) still represents a debated issue. In most cases graft replacement of the ascending aorta, with reinforcement of the sinotubular junction with aortic valve resuspension provides adequate repair of mild to moderate aortic insufficiency associated with A‐ AAD; however, when the AR has dilated a repair or replacement strategy is left to the individual decision since specific thresholds size limits are lacking. We read with particular interest the recent review by Munir et al., in the Journal of Cardiac Surgery, aiming to verify any superiority of AR replacement versus repair in A‐AAD. From this review, no clear evidence favoring either technique has emerged and AR management appears to be left to each surgeon's evaluation. We have recently analyzed our experience in patients with A‐AAD in whom AR was either repaired or replaced and we found that AR preservation provided superior results at 15‐year follow‐up; most importantly, the multivariable analysis indicated that a preoperative AR diameter ≥45mm was the most significant risk factor for proximal reoperation. Undoubtedly, when the aortic valve is deemed not reparable valve or composite AR replacement is mandatory. Conservative treatment of the AR at times may depend on the need to shorten the ischemic time while performing complex distal repairs, but, considering that A‐AAD occurs frequently in young subjects, efforts should be directed whenever possible towards a repair strategy, which avoids the burden of chronic anticoagulation and reduces the need for late distal reoperations. Particularly, the extended application of a valve‐sparing anatomical root reconstruction should be favored, although often quite challenging in this setting. What emerges from our experience does not provide a definite answer to the issue of AR management in A‐AAD, but indicates the effectiveness of a specific size‐oriented strategy. These data may be helpful since patients with A‐AAD are treated in an emergency, in many cases overnight, and often less experienced surgeons are faced with difficult decisions which must be rapidly taken.