Intraoperative Management for Valve-Sparing Aortic Root Replacement

Valve-sparing aortic root replacement (VSARR) has evolved into the preferred surgical procedure for select patients with aortic root aneurysm, offering native-valve hemodynamics and excellent long-term survival without the need for lifelong anticoagulation. This technically demanding procedure requires precise surgical execution and coordinated perioperative management to ensure successful outcomes. This review provides an evidence-based framework for intraoperative anesthetic management during VSARR, including comprehensive pre- and post-cardiopulmonary bypass transesophageal echocardiography (TEE), practical strategies for intraoperative decision making, key procedural steps, and common complications with corresponding TEE findings, including coronary button issues, graft sizing issues, and residual insufficiency. By combining anatomic expertise with detailed echocardiographic assessments and hemodynamic insight to guide surgical decision making, cardiac anesthesiologists can significantly influence procedural success for both short- and long-term valve function.