Ascending Aorta Aneurysm: What is the Risk of Replacing the Aortic

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1 ORIGINAL ARTICLE Ascending Aorta Aneurysm: What is the Risk of Relacing the Aortic Root? Aneurisma de aorta ascendente: cuál es el riesgo de reemlazar la raíz? MARIANO CAMPORROTONDO 1, JUAN CARLOS ESPINOZA 1, FERNANDO PICCININI 1, MARIANO VRANCIC 1, PAZ RICAPITTO 2 *, GUSTAVO AVEGLIANO 2, FERNANDO BELCASTRO 2, AGUSTINA SCIANCALEPORE 2, PAOLA KUSCHNIR 2, DANIEL O NAVIA 1 ABSTRACT Background: In mildly dilated aortic root, the cost-benefit of relacing the sinuses of Valsalva with the resulting reimlantation of the coronary arteries comared with the alternative of reserving them is still a matter of debate Objective: The goal of this study was to analyze the ostoerative and long-term morbidity and mortality of atients undergoing aortic root relacement versus aortic root surgery with sinus of Valsalva Methods: Between 2002 and 2016, 426 atients underwent relacement of the ascending aorta After excluding atients undergoing urgent rocedures, genetic aortic diseases (excet for bicusid aortic valve), reoerations and surgery of the aortic arch, the study cohort was made u of 259 atients The ascending aorta was relaced reserving the aortic root in 99 (382%) of these atients, and they were comared with the remaining 160 (618%) atients who underwent relacement of the sinuses of Valsalva Results: Patients with of the aortic root were older, had higher ercentage of female sex, higher EuroSCORE and with greater incidence of bicusid aortic valve and coronary artery disease Cardioulmonary byass time was longer in the grou undergoing aortic root relacement There were no significant differences in in-hosital mortality between both grous (1% in the grou with of the aortic root vs 31% in the grou with relacement of the sinuses of Valsalva, =0272) Multivariate analysis showed that cardioulmonary byass time was a redictor of in-hosital mortality Survival at 8 years was similar in both grous There were no new oerations due to comlications in the aorta during follow-u At multivariate analysis, age and mitral valve disease were identified as redictors of long-term mortality Conclusion: Relacement of the ascending aorta, either relacing the aortic root or reserving the sinuses of Valsalva, is a safe rocedure, with low in-hosital morbidity and mortality Preservation of the sinuses of Valsalva is not associated with greater long-term rate of events or mortality Key words: Aorta Aortic Aneurysm Sinus of Valsalva RESUMEN Introducción: El riesgo-beneficio del reemlazo de los senos de Valsalva con el consiguiente reimlante coronario frente a la alternativa de mantenerlos, cuando hay dilataciones moderadas de la raíz, es un tóico que se debe definir Objetivo: Analizar la morbimortalidad osoeratoria y a largo lazo en acientes sometidos a reemlazo de la raíz aórtica comarados con aquellos en los que se han resetado los senos de Valsalva Material y métodos: Entre 2002 y 2016, a 426 acientes se les realizó reemlazo de aorta ascendente Tras excluir de esa oblación las cirugías de urgencia, las aortoatías genéticas (exceto bicúside), las reoeraciones y las cirugías del arco, se conformó una oblación de 259 acientes En 99 de ellos (38,2%) se reemlazó la aorta ascendente conservando la raíz; estos acientes fueron comarados con los 160 (61,8%) acientes restantes, en quienes se reemlazaron los senos de Valsalva Resultados: El gruo en el que se reservó la raíz fue más añoso, con más mujeres, con un Euroscore mayor, con mayor incidencia de válvula bicúside y enfermedad coronaria El tiemo de circulación extracorórea fue mayor en el gruo en el que se reemlazó la raíz La mortalidad hositalaria no fue diferente (1% ara la conservación de raíz vs 3,1% ara el reemlazo de los senos de Valsalva ( = 0,272) En el análisis multivariado, el tiemo de circulación extracorórea fue redictor de mortalidad osoeratoria La sobrevida a 8 años no mostró diferencias significativas entre gruos En el seguimiento, ningún aciente requirió reoeración debido a comlicaciones de la aorta En el análisis multivariado, la edad y la resencia de enfermedad valvular mitral fueron redictores de mortalidad alejada Conclusión: El reemlazo de la aorta ascendente, ya sea reemlazando la raíz o resetando los senos de Valsalva, es una cirugía segura, con baja morbimortalidad hositalaria A largo lazo, la reservación de los senos de Valsalva no se asocia con más eventos ni con mayor mortalidad Palabras clave: Aorta - Aneurisma de Aorta Senos de Valsalva REV ARGENT CARDIOL 2018;86: htt://dxdoiorg/107775/racv86i Received: 02/16/2018 Acceted: 06/27/2018 Address for rerints: Dr Camorrotondo, Av Del Libertador 6302, C1428ART, Ciudad Autónoma de Buenos Aires, Argentina mcamorrotondo@icbacomar 1 Deartment of Cardiovascular Surgery, Center for Aortic Diseases, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina 2 Deartment of Cardiology, Center for Aortic Diseases, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina

2 REPLACEMENT OF THE ASCENDING AORTA / Mariano Camorrotondo et al 251 INTRODUCTION When evaluating if a atient should undergo a surgical rocedure, the risk of the interven-tion must be assessed against the risk of the disease In the case of atients with ascending aortic aneurysm, assessment should include the aortic root, the tubular segment of the aorta and the resence or absence of aortic valve involvement (Figure 1A) Clinical ractice guidelines are very clear about when to relace the aorta, but in some atients the risk of erforming reimlantation of the coronary arteries during the rocedure should be evaluated considering the atient s age and the resence of comorbidities (1-5) The risk of relacing the aortic root with reimlantation of the coronary arteries seems to be higher, but the actual imact of this technique comared with relacing only the tubular segment (reserving the sinuses of Valsalva) is not clearly defined in terms of erioerative risk and long-term followu The rimary objective of this study was to evaluate erioerative morbidity and mortality of aortic root relacement with reimlantation of the coronary arteries comared with of the sinuses of Valsalva during relacement of the ascending aorta The secondary objective was to comare the rate of aortic comlications and survival of atients undergoing such rocedures METHODS Study design and atient oulation From May 2002 to May 2016, 426 consecutive atients underwent ascending aorta relacement This analysis excluded non-elective rocedures, genetic aortic diseases (excet for bicusid aortic valve), cardiac reoerations and concomitant surgery of the aortic arch Thus, 259 atients undergoing elective surgery of the ascending aorta were analyzed Among these atients, 99 (382%) underwent relacement of the ascending aorta reserving the aortic root (Figure 1B, left anel), while in the remaining 160 atients (618%) relacement of the ascending aorta included aortic root relacement with reimlantation of the coronary arteries (valve-saring aortic root relacement or comosite valvegraft rocedure) (Figure 1B, right anel) These two grous of atients reresent the core of the study A total of 60 airs were matched using roensity scores The demograhic and clinical characteristics of the atients are resented in Table 1 All the atients data were rosectively collected from our database (Microsoft Access; Microsoft Cor, Redmond, WA), which is used daily for clinical data management Endoint analysis The following early results were analyzed: in-hosital mortality, ostoerative stroke, dee sternal wound infection, acute kidney failure requiring dialysis, ostoerative acemaker imlantation and reintervention due to bleeding Multivariate analysis was erformed in order to identify indeendent redictors of in-hosital mortality Long-term survival was evaluated by direct communication with the atients, their family or attending hysicians, and also through medical records Multivariate analysis was erformed in order to identify indeendent redictors of long-term mortality During follow-u, the aortic diameter was evaluated at the level of the sinuses of Valsalva with Doler echocardiograhy in the atients who did not undergo aortic root relacement Surgical rocedure and indication An aortic diameter of 50 mm or greater in the ascending aorta or aortic root was indication for aortic relacement When the diameter or the aortic root was <50 mm, the indication was left at the discretion of the surgeon All atients were oerated on through a median sternotomy In atients with of the aortic root, the ascending aorta was resected above the sinotubular junction, and either aortic valve relacement or aortic valve reair were erformed in case the aortic valve was involved In the grou of atients with reimlantation of the coronary arteries, relacement of the aortic root and ascending aorta was erformed with a comosite valve graft (with a biologic or mechanical rosthesis) or atients underwent a valve-saring rocedure (remodeling technique Yacoub rocedure or reimlantation technique Tirone David rocedure) (Figure 1B, right anel) A closed distal anastomosis was erformed in all cases and in both grous Statistical analysis Preoerative atient characteristics were exressed as mean ± standard deviation, median and interquartile range (IQR), or revalence (in ercentage), as aroriate Student s t test for indeendent samles or the Mann-Whitney U test Ascending aorta Sinotubular junction Valsalva sinuses Aortic annulus Aortic arch Fig 1 A Anatomy of the aortic root and ascending aorta B Schematic diagram of the study comaring ascending aorta relacement reserving the aortic root (left anel) comared with ascending aorta and aortic root relacement with reimlantation of the coronary arteries in the graft (right anel), using either valve-saring aortic root relacement (Tirone David rocedure or Yacoub rocedure) or comosite valvegraft rocedures

3 252 ARGENTINE JOURNAL OF CARDIOLOGY / VOL 86 Nº 4 / AUGUST 2018 Table 1 Demograhic data and clinical characteristics of the atients included in the study General oulation Grou adjusted by risk score N=99 artery reimlantation N=160 artery reimlantation Women 354% 138% % 174% 0397 Age (years) 663 ± ± ± ± Logistic EuroSCORE 58 ± ± ± ± History of myocardial infarction 51% 13% % 29% 100 History of ercutaneous coronary intervention 61% 19% % 43% 100 Periheral vascular disease 10% 00% % 00% 100 Chronic kidney failure 40% 25% % 14% 0172 Hyertension 697% 625% % 725% 0707 Dysliidemia 485% 344% % 362% 0298 Former smoker 566% 425% % 507% 0495 Diabetes 81% 19% % 29% 0404 Bicusid aortic valve 333% 188% % 261% 0703 Aortic valve disease 899% 963% % 928% 0245 Aortic stenosis 472% 734% % 75% 0002 Aortic regurgitation 528% 266% % 250% 0002 Aortic diameter (mm) 372 ± ± ± ± Ascending aorta (mm) 535 ± ± ± ± Aortic dissection 40% 6% % 14% 100 Mitral valve disease 40% 44% % 43% 100 artery disease 263% 135% % 250% 0547 Single-vessel disease 121% 69% % 130% 0642 Two-vessel disease 40% 31% 29% 58% Three-vessel disease 81% 19% 87% 43% Left main coronary artery disease 20% 13% % 14% 0316 Endocarditis 10% 06% Ejection fraction <35% 111% 163% % 159% 0195 for continuous variables and the chi square test for categorical variables were alied to examine differences between grous A roensity score of undergoing coronary artery imlantation was calculated for each atient using a logistic regression model that included all the reoerative variables listed in Table 1 Patients were matched by roensity score in a 1:1 ratio using the greedy matching technique without relacement A nearest neighbor-matching algorithm was used with calier of The outcomes of interest between the matched grous were comared using the aired t test for continuous variables and the McNemar test for categorical variables Event-free survival curves were estimated with the Kalan- Meier method and the log-rank test was used to assess differences in survival between both grous Univariate and multivariate Cox roortional hazard analyses were erformed to investigate the significant redictors of long-term mortality The clinical variables detailed in Tables 1 and 2 were used for the univariate analysis The variables with <02 on univariate analysis were included in the multivariate model The level of statistical significance was established as <005 Ethical considerations The institutional Ethics Committee aroved the study and surgical consent was obtained from each atient regarding the surgical method and ostoerative evaluations RESULTS Baseline characteristics The reoerative clinical rofile of the study oulation is resented in Table 1 Patients undergoing of the aortic root were older and had higher ercentage of women Logistic EuroSCORE was higher in this grou of atients and the revalence of dysliidemia, diabetes, smoking habits and bicusid aortic valve was greater In addition, this grou resented higher revalence of aortic regurgitation and coronary artery disease The grou undergoing aortic root relacement had more revalence of asymtomatic atients, higher rate of aortic stenosis, and as exected by the study design, the diameter of the aortic root was greater (372±77 vs 492±93

4 REPLACEMENT OF THE ASCENDING AORTA / Mariano Camorrotondo et al 253 mm, <00001) On the contrary, the diameter of the ascending aorta was similar in both grous ( of the aortic root 535±78 mm vs aortic root relacement 559±74 mm; <0066) Surgical data Cardioulmonary byass time was longer in the grou undergoing aortic root relacement, both in the general oulation (151±45 vs 109±35 minutes; <00001) as in the oulation adjusted for risk score (155±37 vs 111±36 minutes; <0001) The grou with of the aortic root received a higher ercentage of biological valve imlantation (779% vs 396%; =00001) and the number of combined coronary artery byass graft surgeries was greater (263% vs 131%; = 0008) though the latter showed no significant difference in the oulation adjusted by risk score The remaining surgical data are summarized in Table 2 Postoerative results There were no significant differences in in-hosital mortality between both grous in the general oulation (1% in the grou with of the aortic root vs 31% in the grou undergoing aortic root relacement =0272) or in the oulation adjusted by risk score (14% vs 43%; =0310) Postoerative stroke was more common in the grou with of the aortic root (3% vs 0%; =0027) but did not resent significant differences in the oulation adjusted by risk score Postoerative vasolegic syndrome was more common in the grou with aortic root relacement (163% vs 71%; =0031), but did not resent significant differences in the oulation adjusted by risk score Other ostoerative comlications as bleeding-related reexloration, low cardiac outut syndrome, atrial fibrillation, acemaker imlantation and need for dialysis was similar in the two grous, both in the general oulation as in the oulation adjusted by risk score Multivariate analysis showed that only cardioulmonary byass time was a redictor of in-hosital mortality (HR: 1022; 95% CI: ; =0003) Table 1 Oerative data and immediate ostoerative results (RP) N=99 General oulation artery reimlantation N=160 Grou adjusted by risk score artery reimlantation Cardioulmonary byass time (min) 109 ± ± ± ± Aortic cross-claming time (min) 88 ± ± ± ± Mechanical rosthesis (n) 152% (15) 604% (67) % (12) 348% (24) 002 Biological rosthesis (n) 535% (53) 396% (44) 565% (39) 348% (24) Aortic valve reair + RP (n) 1% (1) 14% (1) Aortic valve resusension +RP (n) 303% (30) 246% (17) Valved graft with Bentall rocedure (n) 669% (107) 667% (46) Valved graft with Cabrol rocedure (n) 25% (4) 29% (2) relacement with Tirone David 256% (41) 246% (17) rocedure (n) relacement with Yacoub 50% (8) 58% (4) rocedure (n) Combined rocedure with coronary artery 263% 131% % 232% 0693 byass graft Combined rocedure with mitral valve surgery 40% 44% % 43% 1000 In-hosital mortality 10% 31% % 43% year survival 98 ± 14% 975 ± 12% ± 14% 957 ± 25% year survival 946 ± 28% 922 ± 24% ± 34% 877 ± 45% 0210 Reoeration for bleeding 71% 81% % 72% 0753 Low cardiac outut syndrome 30% 44% % 72% 0245 Vasolegic syndrome 71% 163% % 174% 0070 Atrial fibrillation 172% 156% % 203% 0507 Need for acemaker 10% 38% % 14% 0316 Dialysis 00% 13% % 26% 0155 Stroke 30% 00% % 00% 0080 Mediastinitis 00% 06% % 14% 0316

5 254 ARGENTINE JOURNAL OF CARDIOLOGY / VOL 86 Nº 4 / AUGUST 2018 Follow-u and survival Follow-u time was 54±34 years (IQR: 27-8 years) The Kalan-Meier curve showed that survival at 8 years was similar in the two grous, both in the general oulation (=0474) as in the oulation adjusted by risk score (=0210) (Figure 2) Overall survival in the grou with of the aortic root at 1, 5 and 8 years was 98%±2%, 95%±3% and 91%±4%, resectively In turn, in the grou of atients undergoing aortic root relacement, overall survival was 96%±1%, 92%±3% and 88%±3% at 1, 5 and 8 years, resectively During follow-u, none of the atients with of the aortic root required a reoeration due to a comlication associated to its The diameter of the sinuses of Valsalva that were not relaced remained stable at 35 ± 52 mm over time and did not exceed 50 mm in any of the atients Only one atient in the aortic root relacement grou required a re-oeration 6 years after the first surgery due to endocarditis of the valved graft At multivariate analysis, age (HR: 1064; IQR: ; =0011) and mitral valve disease (HR: 7763; IQR: ; =0001) were identified as redictors of long-term mortality DISCUSSION In atients with ascending aortic aneurysms, the surgeon and the attending cardiologist should decide whether to indicate relacement of the aortic root with valved conduits or with of the sinuses of Valsalva in moderate dilations of the aortic root Such decision imlies assuming the risk of reimlantation of the coronary arteries if the sinuses of Valsalva are not reserved or the risk of sinus dilation if they are reserved (6) The rimary objective of this study was to evaluate the risks and benefits in terms of erioerative morbidity and mortality of aortic root relacement with reimlantation of the coronary arteries versus of the sinuses of Valsalva during relacement of the ascending aorta Although in-hosital mortality was statistically similar in both grous, it was three times greater, exressed in ercentage, in the grou with aortic root relacement (31% vs 1%, =0-272) This indicates that aortic root relacement is a more comlex rocedure and involves a certain risk Moreover, the lack of statistical significance after comaring both grous may be due to the number of atients evaluated Interestingly, the rate of stroke was higher in atients with reserved aortic root (with a non-significant difference in the oulation adjusted by risk score), which may be attributed to the fact that this was an older grou, with a higher EuroSCORE and higher revalence of cardiovascular risk factors The multivariate analysis confirmed the imortance of cardioulmonary byass time as a redictor of in-hosital mortality The secondary objective was to comare the aortic comlications and survival of atients undergoing these rocedures During follow-u, mortality was similar in both grous and none of the atients with of the aortic root required a reoeration due to rogressive dilation of the root Age and mitral valve disease were redictors of longterm mortality The resence of mitral valve disease as a redictor of mortality at follow-u is noteworthy and has not been reorted in other series, robably because aortic root relacement combined with mitral valve surgery is a comlex rocedure and could have a negative imact during follow-u (7) We used a cut-off value of 50 mm diameter to decide the relacement of the sinuses of Valsalva This cut-off value does not strictly follow the recommendations of the ractice guidelines which recommend resection of the aortic root when the diameter is > 45 mm (1-5) We oint out that the recommendation of the guidelines is based on studies describing the natural history of aortic aneurysms rather than on comarative studies or clinical trials with different treatment otions (8-11) Milewski et al evaluated 428 atients undergo- Fig 2 Kalan-Meier curves with estimated survival at 8 years in the general oulation (A) and in a sub-oulation adjusted by risk score (B) according to the tye of surgery: of the aortic root vs aortic root relacement Cumulative survival (roortion) P log rank = 0474 P log rank = 0210 relacement with reimlantation of the coronary arteries Patients at risk Cumulative survival (roortion) Years 02 Patients at risk relacement with reimlantation of the coronary arteries Years relacement relacement Years Years

6 REPLACEMENT OF THE ASCENDING AORTA / Mariano Camorrotondo et al 255 ing aortic valve relacement with suracoronary ascending aorta relacement reserving the sinuses of Valsalva (12) Patients were stratified on the basis of valve morhology (tricusid aortic valve vs bicusid aortic valve), valvular athology (aortic stenosis vs aortic regurgitation) and reoerative aortic root dimensions (<40 mm vs mm vs >45 mm) The sinus of Valsalva dimensions remained stable in all the grous over a mean follow-u of 435 months In the few cases requiring re-oeration, the indication was not due to rogressive dilation of the sinuses of Valsalva In a recent study, Hui et al evaluated 426 atients undergoing aortic valve relacement without relacement of the aortic root during a mean follow-u of 81 years, and reorted that the aorta remained stable over time and only one atient required re-oeration due to aneurysmal dilation They concluded that if the aortic root is not dilated at the time of surgery, the risk of enlargement over time is minimal, and rules out the need for rohylactic root relacement (13) Such findings are similar to those of the resent study, suggesting that the remnant sinuses of Valsalva will robably remain stable over time Our study has the limitations inherent to its retrosective design and the size of the cohorts included is limited Nevertheless, it offers information about the daily ractice in a single center, with uniform aroach in decision-making and treatment, which can mitigate the above-mentioned shortcomings Another limitation of this study is the follow-u eriod, though it is similar to the one of other ublications, as that of Peterss et al from the University of Yale In that study, the authors reorted a slow growth of the aortic root in 102 atients over 6 years, regardless of concomitant valve relacement, (14) and estimated that reoerative root dimensions <45 mm would need 29 years to reach 50 mm, a time frame that would only be of imortance in young atients The in-hosital and long-term results of our study are similar to those reorted by other series Using the information about relacement of the ascending aorta retrieved from the Society of Thoracic Surgeons (STS) database with 45,894 atients analyzed, Williams et al reorted an oerative mortality of 341% for elective cases of isolated relacement of the ascending aorta with of the sinuses of Valsalva (15) In the same sense, Di Marco et al reorted a 44% mortality rate for elective rocedures in 1,045 atients undergoing relacement of the sinuses of Valsalva with valved graft Both results are similar to those of the resent study, with a mortality rate of 1% with of the sinuses of Valsalva and 31% with aortic root relacement (16) Are these results enough to convince surgeons and cardiologists that they do not need to worry about the sinuses of Valsalva in atients with moderate dilation of the aortic root (<50 mm)? (17) A randomized study or a large observational study including atients with aortic root diameters <50 mm would be necessary to answer this question, and should include several co-factors (such as age, height, family history of dissection or ruture, connective tissue disorders, valve morhology, and others) The study should also be multicenter, as surgeries of the aortic root and ascending aorta are not commonly erformed in all institutions For examle, in the United States, the median of aortic root surgeries is 2, and only 5% of the articiating institutions in the STS database erform 16% of these surgeries er year (18) CONCLUSION In this study, relacement of the ascending aorta, either relacing the aortic root or reserving the sinuses of Valsalva, is a safe rocedure, with low inhosital morbidity and mortality Preservation of the sinuses of Valsalva is not associated with higher long-term rates of events or mortality Conflicts of interest None declared (See authors conflicts of interest forms on the website/ Sulementary material) REFERENCES 1 Hiratzka LF, Bakris GL, Beckman JA, et al 2010 ACCF/ AHA/ AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of atients with thoracic aortic disease J Am Coll Cardiol 2010; 55:e htt://doiorg/bxfjqd 2 Erbel R, Aboyans V, Boileau C, et al ESC Committee for Practice Guidelines 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult The Task Force for the Diagnosis and Treatment of Aortic Diseases of the Euroean Society of Cardiology (ESC) Eur Heart J 2014; 35: htt:// doiorg/f3kkr 3 Hiratzka LF, Creager MA, Isselbacher EM, et al Surgery for aortic dilatation in atients with bicusid aortic valves: a statement of clarification from the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines Circulation 2016; 133:680 6 htt://doiorg/crc 4 Baumgartner H, Falk V, Bax JJ, et al 2017 ESC/EACTS Guidelines for the management of valvular heart disease Eur Heart J 2017;38: htt://doiorg/gcth4 5 Svensson LG, Adams DH, Bonow RO, et al Aortic valve and ascending aorta guidelines for management and quality measures: executive summary Ann Thorac Surg 2013; 95: htt://doi org/f4tnjj 6 Idrees JJ, Roselli EE, Lowry AM, et al Outcomes after elective roximal aortic relacement: A Matched Comarison of Isolated Versus Multicomonent Oerations Ann Thorac Surg 2016;101: /jathoracsur David TE, Armstrong S, Maganti M, et al Clinical outcomes of combined aortic root relacement with mitral valve surgery J Thorac Cardiovasc Surg 2008;136:82-7 htt://doiorg/d83cr2 8 Coady MA, Rizzo JA, Hammond GL, et al What is the aroriate size criterion for resection of thoracic aortic aneurysms? 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7 256 ARGENTINE JOURNAL OF CARDIOLOGY / VOL 86 Nº 4 / AUGUST 2018 and comlications Ann Thorac Surg 1999;67: htt://doiorg/ dm8sdc 12 Milewski RK, Habertheuer A, Bavaria JE, et al Fate of remnant sinuses of Valsalva in atients with bicusid and trileaflet valves undergoing aortic valve, ascending aorta, and aortic arch relacement J Thorac Cardiovasc Surg 2017;154: htt:// doiorg/cxckww 13 Hui SK, Fan C-PS, Christie S, Feindel CM, David TE, Ouzounian M, The aortic root does not dilate over time after relacement of the aortic valve and ascending aorta in atients with bicusid or tricusid aortic valves J Thorac Cardiovasc Surg (2018) (in ress), doi: /jjtcvs htt://doiorg/gbr63t 14 Peterss S, Charilaou P, Dumfarth J, et al Aortic valve disease with ascending aortic aneurysm: Imact of concomitant root-saring (suracoronary) aortic relacement in nonsyndromic atients J Thorac Cardiovasc Surg 2016;152:791-8 htt://doiorg/f82rtw 15 Williams JB, Peterson ED, Zhao Y, et al Contemorary Results for Proximal Aortic Relacement in North America J Am Coll Cardiol 2012;60: htt://doiorg/f2m9vm 16 Di Marco L, Pacini D, Pantaleo A, et al Comosite valve graft imlantation for the treatment of aortic valve and root disease: Results in 1045 atients J Thorac Cardiovasc Surg 2016;152: htt://doiorg/f9dxc 17 Feindel CM, Ouzounian M To relace or not to relace mild to moderately dilated sinuses of Valsalva: When less is more J Thorac Cardiovasc Surg 2017;154:433-4 htt://doiorg/crd 18 Stamou SC, Williams ML, Gunn TM, Hagberg RC, Lobdell KW, Kouchoukos NT surgery in the United States: a reort from the Society of Thoracic Surgeons database J Thorac Cardiovasc Surg;2015;149: htt://doiorg/f64q7m