overall conclusions drawn by the authors and plead for an active pursuit of obtaining male–female-specific insights into the treatment of thoracic aortic disease. In this light, the “one-size-fits-all” philosophy should be abandoned and patient-tailored solutions (male/female) should be explored further. Maximiliaan L. Notenboom, BSc Jos A. Bekkers, MD, PhD Johanna J. M. Takkenberg, MD, PhD Department of Cardiothoracic Surgery Erasmus University Medical Center Rotterdam, The Netherlands References 1. Elefteriades JA, Rizzo JA, Zafar MA, Ziganshin BA. Ascending aneurysmectomy: should we shift to the left? J Thorac Cardiovasc Surg. 2023;166:435-41. 2. Saeyeldin AA, Velasquez CA, Mahmood SUB, Brownstein AJ, Zafar MA, Ziganshin BA, et al. Thoracic aortic aneurysm: unlocking the “silent killer” se- crets. Gen Thorac Cardiovasc Surg. 2019;67:1-11. 3. Thijssen CGE, Dekker S, Bons LR, G€okalp AL, Kauling RM, van den Bosch AE, et al. Health-related quality of life and lived experiences in males and females with thoracic aortic disease and their partners. Open Heart. 2020;7:e001419. 4. Treasure T, King A, Hidalgo Lemp L, Golesworthy T, Pepper J, Takkenberg JJ. Developing a shared decision support framework for aortic root surgery in Marfan syndrome. Heart. 2018;104:480-6. 5. Van Hoof L, Rega F, Golesworthy T, Verbrugghe P, Austin C, Takkenberg JJM, et al. Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients. Heart. 2021;107:1790-5. https://doi.org/10.1016/j.jtcvs.2022.08.034 STENTLESS ROOT REPLACEMENT PROVES SUPERIOR HENCE VERSATILE: “THE ROOT IS A ROOT OF THE PROBLEM” To the Editor: “blood.percusses against the front of the arches of the hemicycles (sinus), and follows the concavity of this hemicycle, until it percusses against the concavity at the base of this hemicycle (cusps)”— Leonardo da Vinci, glass model of aortic valve 1507-08. The study by Yerokun and colleagues 1 reports midterm risk-adjusted survival and clinical outcome by aortic root replacement (ARR) strategy in 4173 Medicare benefi- ciaries, 65 years or older, based on the Society of Thoracic Surgeons Database. At 7 years, survival was significantly lower after mechanical ARR than stentless and stented ARR. However, the stentless ARR strategy also presented superiority in secondary end points, including freedom from stroke, which was identical to valve-sparing root replacement but had a significantly lower redo rate. Like- wise, readmissions due to bleeding were the lowest in this group. The authors should be congratulated on a success- fully established and well-conducted contemporary, retro- spective, high-volume study based on the benchmark Society of Thoracic Surgeons Database, which may be essential to the decision-making process in the future. How- ever, the clear superiority of stentless root replacement has not been highlighted. Instead, recommendations were based on the easy potential for the valve-in-valve procedure after stented ARR. Renewed interest in stentless root-replacement strategy is well illustrated by multicenter clinical data proving its ver- satile applicability. 2 Randomized long-term data confirm superior durability and valve function over homografts, with survival equivalent to matched population and valve function to autografts. 3 The superiority of stentless implan- tation lies in lower gradients and larger effective orifice area, and it has been confirmed in randomized studies. 4,5 A recent comparison of 340 ARR versus 193 root enlarge- ments for aortic valve stenosis also has shown better hemo- dynamics in stentless ARR. 6 The risk of neoroot dilatation and pseudoaneurysm discussed by the authors evoked ad- vancements in implantation techniques milieu, adding ele- ments of wrapping to the procedure, well documented in the literature on ARR with autografts. 7 In addition, stentless ARR offers much technical versa- tility. A modified “cylinder within cylinder root replacement” that I have published recently may reduce the operative risk and eliminate the issue of porcine root dilatation but not compromise the sizing strategy and hemodynamics at the same time. 8 Clinically proven hemodynamical superiority, so relevant during exercise, should remain an essential argu- ment during the decision-making process, bearing in mind the increasingly active life-style of society. 9 Stentless ARR, proven by recent data and unique technical versatility, de- serves to remain a contemporary benchmark operation. 10 Marek Jasinski, MD, PhD, FETCS Kinga Kosiorowska, MD Mikolaj Berezowski, MD Department of Cardiac Surgery Wroclaw Medical University Wroclaw, Poland The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and re- viewers of this article have no conflicts of interest. Adult: Aorta: Letters to the Editor e62 The Journal of Thoracic and Cardiovascular Surgery c August 2023 ADULT