title: Root replacement surgery versus more conservative management during type A acute aortic dissection repair.
abstract: BACKGROUND
  Aortic root management in type A acute aortic dissection is controversial. This study compared outcomes of root replacement (RR) interventions versus more conservative root (CR) management.
  
  
  METHODS
  Of 1,995 type A acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection, 699 (35%) underwent RR interventions and 1,296 (65%) underwent CR management. Independent predictors of hospital and 3-year survival were identified using multivariable logistic and Cox regression models.
  
  
  RESULTS
  Compared with CR patients, RR patients were younger (56.9 versus 62.3 years; p = 0.023) and more likely to present with larger root diameter (4.7 cm versus 4.0 cm; p < 0.001), Marfan syndrome (8.7% versus 2.5%; p < 0.001), aortic insufficiency (64.0% versus 50.3%; p < 0.001), and hypotension, shock, or tamponade (33.0% versus 26.5%; p = 0.003). Root replacement management did not increase hospital mortality (propensity score-adjusted odds ratio, 1.14; p = 0.674). On Kaplan-Meier analysis, 3-year survival (RR, 92.5% ± 1.7% versus CR, 91.6% ± 1.3%; log-rank p = 0.623) and freedom from aortic root reintervention (RR, 99.2% ± 0.1% versus CR, 99.3% ± 0.1%; log-rank p = 0.770) were similar. Only 2 patients (1 per group) underwent follow-up root reintervention. Propensity score-adjusted Cox regression excluded a relationship between root treatment and follow-up survival (hazard ratio, 1.5; 95% confidence interval, 0.502 to 5.010; p = 0.432).
  
  
  CONCLUSIONS
  In type A acute aortic dissection patients more-extensive RR interventions are not associated with increased hospital mortality. This supports such an approach in young patients and patients with connective tissue diseases and bicuspid aortic valves. Excellent midterm survival and freedom from root reintervention in both groups suggest stable behavior of the nonreplaced aortic sinuses at 3 years. Thus, pending studies with longer follow-up, the use of aggressive RR techniques can be determined by patient-specific and dissection-related factors.
authors.affiliation: Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy. Electronic address: marco.dieusanio2@unibo.it.
authors.forename: Marco
authors.initials: M
authors.lastname: Di Eusanio
authors.affiliation: Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato, Italy.
authors.forename: Santi
authors.initials: S
authors.lastname: Trimarchi
authors.affiliation: Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Peterson
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Tromsø University Hospital, Tromsø, Norway.
authors.forename: Truls
authors.initials: T
authors.lastname: Myrmel
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: G Chad
authors.initials: GC
authors.lastname: Hughes
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Amit
authors.initials: A
authors.lastname: Korach
authors.affiliation: Thoracic Aortic Center, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Thoralf M
authors.initials: TM
authors.lastname: Sundt
authors.affiliation: Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Di Bartolomeo
authors.affiliation: Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors.forename: Kevin
authors.initials: K
authors.lastname: Greason
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Ali
authors.initials: A
authors.lastname: Khoynezhad
authors.affiliation: Division of Cardiac Surgery, University of Calgary Medical Centre, Calgary, Alberta, Canada.
authors.forename: Jehangir J
authors.initials: JJ
authors.lastname: Appoo
authors.affiliation: Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Folesani
authors.affiliation: Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: De Vincentiis
authors.affiliation: Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Montgomery
authors.affiliation: Thoracic Aortic Center, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Isselbacher
authors.affiliation: Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan.
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.affiliation: Department of Internal Medicine, University of Rostock, Rostock, Germany.
authors.forename: Christoph A
authors.initials: CA
authors.lastname: Nienaber
authors.affiliation: Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan.
authors.forename: Himanshu J
authors.initials: HJ
authors.lastname: Patel
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D002170:Canada / Q000453:epidemiology; D005060:Europe / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology