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Aortic root surgery is an operation used to treat problems in the first part of the aorta, which is the large blood vessel of the body. This area also contains the aortic valve, which controls blood flow out of the heart. Surgery may be recommended if the aorta becomes enlarged (aneurysm), if there is a risk of tearing (dissection), or if the valve is not working properly. There are different surgical options depending on the condition. In valve-sparing procedures, such as reimplantation or remodeling, the surgeon repairs the aorta while keeping your own valve, which can help avoid the need for long-term medication. In other cases, a Bentall procedure may be performed, where both the aortic root and valve are replaced together using a composite graft and a new valve. The goal of all these approaches is to make the aorta safe, restore normal blood flow, and support a good quality of life.
When both the aortic root and the aortic valve are affected by disease, a procedure called the Bentall operation is often recommended. In this surgery, the damaged section of the aorta and the faulty valve are removed and replaced together using a single unit called a composite graft. This graft is a durable synthetic tube (often described as a “plastic tube”) that already has a replacement valve sewn inside it. The valve can be either a biological (tissue) valve made from pig (porcine) or cow (bovine) tissue, or a mechanical valve. During the operation, the coronary arteries, which supply blood to the heart muscle, are carefully reattached to the new graft. This approach allows the surgeon to restore both the structure of the aorta and the function of the valve in one procedure, providing a reliable and durable solution for patients with complex aortic root disease.
For some patients, the aortic valve itself is healthy and working well, and the problem lies mainly in the wall of the aorta, which has become weakened and enlarged (an aneurysm). In these situations, it is often possible to preserve your own natural valve while treating the diseased aorta. This is done using valve-sparing aortic root surgery. During the operation, the weakened portion of the aortic root is replaced with a durable, flexible synthetic tube, while your own valve is carefully repaired and supported. Two well-established techniques are commonly used: “Remodeling,” which reshapes the aortic root to restore its natural geometry, and “Reimplantation,” which secures the valve inside the new graft to provide additional stability. Preserving your native valve has important advantages, including more natural valve function, avoidance of long-term blood-thinning medication, and excellent long-term outcomes in appropriately selected patients.
The Aortic Root Re-implantation or David procedure, also known as valve-sparing aortic root replacement, is a technique used when the aortic root is enlarged but the aortic valve itself is still healthy. It is particularly well suited for patients with genetic aortic wall disorders (such as ACTA2 mutations or Marfan syndrome), as it removes all of the diseased aortic tissue while preserving the patient’s own valve. Provided the valve is functioning well (or can be successfully repaired) this approach can offer a durable, long-term solution. By keeping the native valve, patients can avoid lifelong blood-thinning medication and maintain more natural heart function, with excellent long-term outcomes in appropriately selected cases. Over time, the traditional David operation has evolved to incorporate the use of Valsalva grafts, which are designed to mimic the natural shape of the aortic root. These grafts help restore more normal blood flow patterns and valve motion, potentially improving durability and long-term valve performance.
A hemi-root procedure is a more limited form of aortic root surgery used when only part of the aortic root is affected, while the rest—especially the aortic valve and surrounding structures—remains healthy. Instead of replacing the entire root, the surgeon removes and replaces only the diseased portion of the aortic wall with a synthetic graft, preserving as much of the patient’s natural anatomy as possible. This approach is commonly performed in patients with ascending aortic aneurysms, where the enlargement extends into part of the root, and it can also be carried out alongside (concomitant with) aortic valve repair or replacement if needed. Importantly, it allows the surgeon to avoid operating on the remaining two-thirds of the aortic root and the origins (ostia) of the coronary arteries, which can simplify the procedure and reduce surgical risk. By limiting the extent of surgery, hemi-root procedures can shorten recovery time while still effectively treating the problem and maintaining or restoring normal valve function.
In certain cases of aortic root surgery, particularly when there is infection (endocarditis) or complex disease of both the valve and surrounding tissue, surgeons may use a homograft or a stentless bioprosthesis. A homograft is a human donor aortic root, which includes the valve and surrounding tissue, allowing for a very natural reconstruction of the aortic root and excellent resistance to infection. Stentless bioprosthetic roots, typically made from treated animal tissue, offer similar advantages by closely mimicking the native anatomy and providing good blood flow dynamics without the rigid frame seen in standard valve replacements. Both options can be particularly useful in complex or redo surgeries, offering good hemodynamic performance and avoiding the need for lifelong anticoagulation, although their long-term durability may be more limited compared to mechanical options.
The Ross procedure is a heart operation used to treat a diseased aortic valve, particularly in children, young adults, and active patients. In this procedure, the surgeon replaces the damaged aortic valve with the patient’s own pulmonary valve – a healthy valve from the right side of the heart that functions in a very similar way. A donated (cadaveric) valve is then used to replace the pulmonary valve. Because the new aortic valve is the patient’s own living tissue, it works naturally, can grow with the body, and usually does not require lifelong blood-thinning medication. This makes it an excellent alternative to artificial valves, especially for younger patients.
A newer refinement, known as the Ross–PEARS procedure (Personalised External Aortic Root Support), aims to further improve long-term outcomes. In this approach, a soft, custom-made mesh is placed around the patient’s own healthy pulmonary artery, with the valve (pulmonary autograft), which is transplanted to replace the diseased aortic root, with the aortic valve. The ExoVasc® PEARS supports the pulmonary autograft and prevents dilation. This added reinforcement helps the valve maintain its shape and function under higher pressures. Modern experience shows that, when performed in specialist centres, the Ross procedure (especially with PEARS support) offers excellent durability, natural valve performance, and a high quality of life for suitable patients.
The aortic root operations are performed with the heart stopped (using medication) and blood is re-routed to a heart-lung machine. Your surgeon will open the heart chamber, remove the faulty aortic root and sew in the replacement. While this is happening your coronary arteries will be detached and reattached to the new aortic root. Blood is then redirected back to your heart and the heart is restarted. The operation usually takes about 4-5 hours.These operations typically requires a hospital stay of 5-7 seven days.
