The Evolution of Aortic Root Surgery

Abstract Aortic root pathologies were once considered untreatable, and though significant innovations have been made, this area continues to represent a complex clinical challenge. Aortic root surgery has experienced significant innovations over the past several decades. Cardiopulmonary bypass allowed for the first successful repairs of thoracic aortic aneurysms. Following this, there were many developments of composite valve–graft replacement, such as the Bentall procedure. Several technical refinements occurred to address challenges related to coronary reimplantation, bleeding concerns, and pseudoaneurysm formation. Also, valve-sparing aortic root replacement techniques emerged for patients to preserve native valve leaflets, most notably the remodeling (Yacoub) and reimplantation (David) approaches. Among these, the reimplantation technique has demonstrated superior durability with lower rates of late aortic insufficiency and reintervention and is now the most widely adopted valve-sparing strategy. Along with these techniques, methods for aortic annular and root enlargement were developed to address hypoplastic annuli and to reduce patient–prosthesis mismatch, which evolved early from the Nicks and Manougian procedures to the more recent Y-incision technique, which allows for the implantation of larger prosthetic valves with improved hemodynamic profiles and early data revealing promising results. Indications for aortic root intervention are guided by aneurysm size, growth rate, valve dysfunction, genetic aortopathies, and associated complications such as dissection or endocarditis. These guidelines also recognize the importance of utilizing a heart team approach for these patients. Outcome data have demonstrated improved operative mortality and comparable long-term survival between composite graft and valve-sparing approaches, with technique selection influenced by valve morphology, patient comorbidities, and long-term anticoagulation considerations. This review summarizes the historical evolution, operative strategies, indications, and outcomes of aortic root surgery.