Comparative Outcomes of Aortic Root Preservation Versus Root Replacement for Acute Type A Aortic Dissection: Balancing Survival, Durability, and Reoperation

We reviewed the available literature on patients undergoing aortic repair for acute type A aortic dissection (ATAAD) with either aortic root preservation (RP) or root replacement (RR). Original research studies that evaluated the long-term outcomes of RP versus RR group were identified, from 2000 to 2025. Median overall survival (OS) was the primary endpoint. Reoperation-free OS was the secondary endpoint. Sensitivity analyses were performed including risk-adjusted populations, subgroups, and using the leave-one-out method. Seventeen studies were included in the qualitative and quantitative synthesis, incorporating data from 7,569 patients with a follow-up period up to twenty-five years. According to our analysis, RP (4,266 patients) demonstrated higher OS compared to RR (2,589 patients) groups (HR: 0.83; 95% CI:0.76, 0.91; p<0.01). The median OS was 13.57 years for the RP group and 13.48 years for the RR group. Nonetheless, the reoperation-free OS was higher in the RR group (HR: 1.39; 95% CI: 1.16, 1.67; p<0.01). Valve-sparing RR (VSRR) demonstrated the highest long-term OS (p<0.05). Root preservation is associated with superior overall survival but a higher risk of reoperation, while root replacement offers greater durability with fewer reoperations, and VSRR may provide the optimal balance of longevity and native valve preservation, warranting further prospective studies.