Introduction
Acute type A aortic dissection (ATAAD), is a surgical emergency with the
potential for catastrophic consequences because of any delays in
intervention, with a lethality rate of 1-2% per hour following symptom
onset1. Annual incidences reported from 2.5-6 per
100,000 patient-years2, reaching as high as 8.7 per
100,000 patient-years likely resulting from our ageing population as a
leading contributor.3 ATAAD, a disaster where the
repair process is never clear nor obvious, with every second crucial to
saving the patient’s life.
In cases of ATAAD, often there is the involvement of the aortic root
potentially resultant of extension of the primary tear. It is possible
that root pathologies independent of the primary tear are discovered and
may result in concomitant treatment. Surgical intervention on the aortic
root remains controversial and debatable. 4,5,6,7
Acute aortic dissection repair can necessitate a variety of operations,
from simple replacement of the ascending aorta to aortic root
replacement or a version of total arch replacement. There are differing
opinions regarding what constitutes the “appropriate” repair of the
acutely dissected aorta, 4-8, 13-27 a tear tailored
approach is a trend that we normally follow; however, this is not
generalizable across many different centers.
During the surgical repair, when it comes down to the fate of the aortic
root there remains a large amount of controversy in the
literature.4,5,6,7 The following remains unanswered :
- Should a surgeon perform the Bentall procedure, radically replacing
the complete root with all its sinuses, or conservatively repair the
primary damage and preserve the native root structures?
- What are the implications of these decisions on mortality, and the
risks of re-operation?
Another rather ambiguous matter remains which is decision-making
framework on aortic root intervention. This is rather scattered with
different complexities seen in ATAAD, hence, no quantitative assessment
exits. The implementation of optimum treatment strategies from the
initial diagnosis to complete repair can improve the prognostic outcome,
from the mortality of 90% without intervention to upwards of a 70%
chance of survival.8 Henceforth, thoughtful decision
making process, operative planning, meticulous surgical technique, and
intrinsic understanding of hypothermic circulatory arrest and central
nervous system preservation are all sought for optimum outcomes.