Aortic Root Replacement: Should We Wait Until 5 cm?

Surgical replacement of the ascending aorta and root was first undertaken in the 1950s although methodologies were rudimentary compared to the current era. Advances in brain protection and surgical technique have made complex root procedures relatively low risk in experienced hands. The standard critieria for elective replacement of the root and ascending aorta has been 5.5 cm when there is no connective tissue etiology for the aneurysm. Recent literature has suggested that a more liberal criteria would may be appropriate in healthy patient at low risk, patients with high-risk features including strong family history of adverse aortic events, and in centers whose outcomes are such that the risk of surgery at lower aortic size is far less than the risk of progression of disease or significant adverse event. This manuscript critically evaluates recent literature to suggest in which patients and at what type of centers a more aggressive prophylactic approach should be entertained.