Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit

Composite valve graft implantation described by Bentall and De Bono is a well-documented technique of aortic root replacement used for a large spectrum of pathologic conditions involving the aortic valve and the ascending aorta. While mechanical valves were initially used, biological prostheses were later introduced in order to avoid long-term anticoagulation and its related complications. The increasing age of patients who undergo aortic root surgery, and data supporting the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. However, parallel to the increased use of biological valve in the context of a Bentall operation, aortic valve-sparing (AVS) operation have also been performed in a growing number of patients. Sarsam and David described the remodeling and the reimplantation procedures more than 25 years ago with the aim of sparing otherwise normal aortic valves in the presence of a root aneurysm. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with different cusp anatomy. Both procedures can now provide excellent root reconstruction and adequate clinical results in terms of late valve durability. The AVS technique offers several advantages over the Bentall procedure, such as no need for oral anticoagulation and lifestyle adjustments. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology. However, data comparing the safety and durability of these approaches are lacking.