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Elective root replacement of the ascending aorta in people with Marfan syndrome has been established practice for more than 25 years; it greatly reduces the risk they face from fatal aortic dissection.1 Now that low perioperative risk is assured and long-term survival is expected, long-term consequences and the durability of the surgery have become important considerations. The question for people with Marfan syndrome, their families and their surgeons is whether to choose the valve-sparing or valve-replacement forms of surgery. This question is at the core of the systematic review and meta-analysis published in this issue of Heart (see page 955).2 The decision as to which option to prefer is dominated by a trade-off between these competing risks; the analysis presented informs the choice but does not make it any easier. How would an individual patient weigh the risk of stroke versus a given possibility of the need for reoperation? The calculated estimates of the thromboembolic hazards associated with a mechanical valve at 0.7% per year, and the risk of native valve failure mandating reoperation at 1.3% a year, are the central conclusions of this report.
The review incorporates 12 publications from 1995 to 2009, comprising reports of 35–675 patients, with a total of 1434. The average age of the patients at the time of surgery was 34 years. The systematic reviewers could not find data on the degree of aortic regurgitation, or the aortic root dimensions before surgery, which are two of the important criteria used in decision-making1 and would have informed readers of the severity of disease in patients in whom surgery was undertaken. But the large majority of patients with Marfan syndrome develop aortic root dilatation and we know that if this is allowed to continue unchecked then about …