State-of-the-Art Review of Aortic Root Reconstruction: Contemporary Techniques and Challenges

Abstract

Aortic root reconstruction operations have undergone substantial evolution with technical modifications, expanding indications, and the need for increasingly complex decision-making. The purpose of this state-of-the-art review is to detail our approach to contemporary aortic root reconstruction operations. First, we review the evolution of root reconstruction procedures over the years and discuss the approach to the aortic root patient for lifetime management of aneurysm and valvular disease in the modern context of management options. We also discuss state-of-the art technical considerations of valve-sparing root replacement, variations of the Ross operation, aortic valve repair principles and challenges in special populations, and considerations for complication-free coronary button reconstruction. We also discuss root reconstruction in high-risk subpopulations including acute type A aortic dissection, congenital, and reoperative patients. We briefly highlight future directions in transcatheter root replacement as well as the outlook for the next generation of aortic root surgeons.

Keywords: aneurysm; aortic root reconstruction; valve-sparing root replacement; valvular disease.

Visual abstract

Fig. 1.

Patient selection for a Ross procedure. STJ, sinotubular junction.

Fig. 2.

Schematic, echocardiographic, and intraoperative illustrations of the 3 groups of phenotypes of the repair-oriented BAV classification. Reprinted with permission under STM Signatory agreement from de Kerchove et al., “Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification,” Eur J Cardiothorac Surg, Oxford University Press, © 2019. BAV, bicuspid aortic valve.