title: Composite aortic root replacement in acute type A dissection: time to rethink the indications?
abstract: OBJECTIVE
  The indications for aortic root replacement in acute type A dissection are unclear. We reviewed the immediate and long-term outcome of consecutive patients in a series in which a low-threshold policy of composite aortic root replacement had evolved.
  
  
  METHODS
  From a prospectively compiled aortic surgery database, we identified 162 patients who had either supracoronary interposition grafting, Group A (n=89), or composite root replacement, Group B (n=73) for acute type A dissection. Patients receiving total arch replacements were excluded. Operative and clinical details were analyzed and patient survival was compared to an age and gender matched census cohort. Need for reoperation on the proximal or distal aorta was also noted. Follow-up totaled 795.5 patient-years.
  
  
  RESULTS
  Hospital mortality rates were identical in both groups (12.3%: 11 deaths in group A; 9 in group B). Chronic pulmonary disease, diabetes, malperfusion, hemodynamic compromise and aortic root dilatation were independent risk factors for hospital death. Actuarial survival estimates at 1, 5 and 10 years were 79% (71-88%), 64% (53-75%), and 55% (41-68%) for group A, and 79% (70-86%), 73% (62-83%), and 65% (52-78%) for group B (P=0.48). Age and operative patency of the ascending false lumen were independent risk factors for death after hospital discharge. Proximal aortic reoperation was required for four patients in group A and none in group B (P=0.085).
  
  
  CONCLUSIONS
  A strategy of replacement rather than repair of the dissected aortic root for specific indications in type A dissection yielded high survival and low proximal reoperation rates. These results support an aggressive policy of composite root replacement in acute type A dissection.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Halstead
authors.forename: David
authors.initials: D
authors.lastname: Spielvogel
authors.forename: Dieter M
authors.initials: DM
authors.lastname: Meier
authors.forename: Sindy
authors.initials: S
authors.lastname: Rinke
authors.forename: Carol
authors.initials: C
authors.lastname: Bodian
authors.forename: Ramin
authors.initials: R
authors.lastname: Malekan
authors.forename: M Arisan
authors.initials: MA
authors.lastname: Ergin
authors.forename: Randall B
authors.initials: RB
authors.lastname: Griepp
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D002423:Cause of Death; D004812:Epidemiologic Methods; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D019106:Postoperative Hemorrhage / Q000209:etiology; D012086:Reoperation / Q000706:statistics & numerical data; D016896:Treatment Outcome