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Background To determine the progression of aortic root in acute type A aortic dissection (ATAAD) patients after aortic root repair (ARr) or replacement (ARR) based on long‐term follow‐up imaging studies. Methods From 1996 to 2019, 732 patients had ATAAD repair at our institution. Six hundred and seven of these patients had either ARr, (n = 383) or ARR (n = 224). Eighty‐one patients were excluded due to a lack of postoperative imaging. Three hundred and thirty‐two patients were included in the repair group and 194 patients in the replacement group for long‐term follow‐up imaging study. Results Compared to the ARR group, the ARr group was significantly older (60 years vs. 55 years) and had more patients with hypertension (79% vs. 63%) but less male patients (63% vs. 79%) and connective tissue disorder (1.8% vs 8%). The ARr group had more zone two arch replacement (22% vs. 11%), similar HCA time (35 min vs. 31 min), shorter cardiopulmonary bypass time (203 min vs. 266 min), aortic cross‐clamp time (128 min vs. 214 min), and fewer concomitant coronary artery bypass (3.9% vs. 8.9%). The root growth rate over 12 years was similar between the repair and replacement group (0.20 mm/year vs. 0.18 mm/year, p = .75). Both the repair and replacement group had similar 15‐year cumulative incidence of reoperation (6.9% vs. 5.9%; p = .67), operative mortality (7.8% vs. 8.5%; p = .78), and 15‐year survival (51% vs. 52%; p = .40). Conclusions There was minimal growth of the aortic root after root repair or replacement for ATAAD patients. Both aortic root repair and replacement were acceptable techniques for ATAAD surgery in select patients.

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