Should the transverse aortic arch be replaced simultaneously with aortic root replacement for annuloaortic ectasia in Marfan syndrome?

Objective: The purpose of this study was to determine, on the basis of the late fate of the intact aortic arch with abnormal tissue after aortic root replacement, whether the intact aortic arch should be replaced prophylactically at the time of aortic root replacement for annuloaortic ectasia in Marfan syndrome. Methods: A retrospective review was performed in 85 patients with Marfan syndrome who underwent aortic root replacement for annuloaortic ectasia with or without aortic dissection (mean age 37 years, range 19-61 years). These 85 patients were divided into four groups according to the postoperative condition of the residual aorta. In group I (n = 47), the patients underwent aortic root replacement for annuloaortic ectasia with or without localized dissection in the ascending aorta. In these patients the residual aorta, including the aortic arch, was therefore intact. In group 11 (n = 10), the aortic arch was intact, although the descending thoracic aorta was dissected because of the preoperative type B dissection. In groups III and IV, the patients had type A dissection involving the transverse arch associated with annuloaortic ectasia. In group Ill (n = 13), residual dissection existed in the descending thoracic aorta after concomitant total arch replacement. In group IV (n = 15), the aortic arch and the descending thoracic aorta were dissected. Results: There were 5 early deaths (3 in group 1, 1 in group 11, and I in group III). Subsequent operations were required in 10, 5, 6, and 7 cases in groups 1, 11, 111, and IV, respectively. Regarding the aortic arch, only 2 of 53 survivors of the initial hospitalization with an intact aortic arch (groups I and 11) underwent subsequent total arch replacement for the onset of dissection in the aortic arch, and 4 of 14 survivors of the initial hospitalization with a residual dissecting arch (group 111) needed subsequent total arch replacement. Actuarial freedom from arch repair among patients with an intact aortic arch (91% at 15 years) was significantly higher than that among patients with a residual dissecting arch (49% at 15 years, P = 078). Conclusions: The incidence of new dissection in the residual intact arch after aortic root replacement was extremely low. Therefore prophylactic replacement of the intact arch does not appear to be necessary at aortic root replacement for annuloaortic ectasia in Marfan syndrome.