The following are key points to remember from the JACC historical breakthroughs in perspective in type A aortic dissection:

1. The Stanford classification of aortic dissection, described in 1970, proposed that type A aortic dissection should be surgically repaired immediately, whereas type B aortic dissection can be treated medically.
2. In the contemporary era, diagnostic tools and management of acute type A aortic dissection (ATAAD) have undergone substantial evolution. This paper describes historical changes of ATAAD repair at Stanford University since the establishment of the aortic dissection classification 50 years ago.
3. While technical complexity increased over time, postoperative survival continued to improve.
4. The extent of proximal aortic repair has changed in recent years. Stanford’s approach to the aortic valve and root during the early era had been conservative with commissural resuspension, sinus repair, and supracoronary aortic grafts. There is now increased utilization of root replacement such as valve-sparing root replacement.
5. The current standard approach at Stanford for arch involvement in dissection is an aggressive hemiarch replacement at the minimum for patients with dissection extending into the arch, with the hope of decreasing the aortic arch reoperation rate.
6. The development of advanced cerebral perfusion technologies has enabled performance of extensive operations in the arch safely.
7. Patients presenting with or referred for suspected ATAAD should be routed directly to the operating theater or hybrid room. Once the patient arrives in the operating room, the cardiac anesthesia team should induce the patient and perform a thorough transesophageal echocardiography examination to confirm the diagnosis of ATAAD. This protocol significantly reduces the delay in treating this high-risk patient population and streamlines the process.
8. Additional evidence is needed to demonstrate whether certain patients can benefit from a preliminary endovascular intervention, to further delineate the impact of this approach and identify the target population that requires aggressive hybrid interventions.
9. Studies are also needed to delineate factors associated with the improved outcomes observed in this study and to define patient subsets who benefit from aggressive versus conservative surgical management.
10. Finally, policy makers should re-evaluate the infrastructures and feasibility to optimize care for this high-risk patient population and consider rational regionalization.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound

Keywords: Anesthesia, Aneurysm, Dissecting, Aorta, Thoracic, Cardiac Surgical Procedures, Cerebrovascular Circulation, Echocardiography, Transesophageal, Endovascular Procedures, Operating Rooms, Perfusion, Vascular Diseases, Vascular Surgical Procedures

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