Type A acute aortic dissection with ≥40-mm aortic root: results of conservative and replacement strategies at long-term follow-up

OBJECTIVES: We evaluated the long-term results of aortic root (AR) preservation and replacement in patients operated on for acute type A aortic dissection.METHODS: Out of 302 patients discharged after repair of acute aortic dissection (1977-2019), 124 patients had an AR ≥40 mm, which was preserved in 84 (68%, group A) patients and replaced in 40 (32%, group B) patients. Group B patients were younger (mean age 57±12 vs 62±11years, P=0.07), with a mean AR of 47 vs 43mm and ≥moderate aortic insufficiency in 65% vs 30%. Survival, causes of death and reoperations were analysed at mean follow-up of 9±8years (6months to 40years).RESULTS: Actuarial survival of discharged patients at 5, 10 and 15years was 97% (0.89-0.99), 78% (0.67-0.90) and 75% (0.64-0.88) in group A, and 85% (0.71-0.95), 62% (0.44-0.78) and 57% (0.39-0.76) in group B (log-rank test P=0.2). Nine patients in group A (7 patients for aortic insufficiency and dilatation of the root and 2 patients for pseudoaneurysm) and 1 patient of group B (pseudoaneurysm of the right coronary button) required proximal reoperation without deaths. At 5, 10 and 15years, the cumulative incidence of proximal aortic reoperations was 5%, 9% and 25% in group A, and 0%, 3% and 3% in group B (P=0.02). At multivariable analysis AR >45 mm [hazard ratio (HR) 6.8, P=0.026] and age (HR 0.9, P=0.016) were independently associated with proximal reoperation.CONCLUSIONS: AR preservation in acute type A dissection showed acceptable long-term outcomes. Nevertheless, a more aggressive approach appears a valid option, especially in patients with AR diameter >45mm.