The "floating" valve, a modified bioroot Bentall procedure

With a rising incidence of aortic root disease globally, the Bentall procedure remains the gold standard for aortic root replacement. Unfortunately, the classic mechanical heart valves (MHVs) often employed in these surgeries require lifelong anticoagulation, carrying serious bleeding or thrombo-embolic risks and incurring significant lifestyle changes for patients. Recent advances have shifted focus towards biological heart valves (BHVs), leading to the emergence of a bioroot Bentall which can integrate a "floating" BHV within a synthetic vascular conduit. We reviewed contemporary evidence on this surgery to define indications, outcomes and knowledge gaps. This narrative review highlights surgical techniques, patient selection criteria, and surgical outcomes. Uniquely, "floating" valve placement improves hemodynamics and reduces prosthesis-patient mismatch. Additional advantages included valve-in-valve (ViV) feasibility and easier coronary re-access, while persisting barriers were uncertain long-term BHV durability and a lack of long-term randomized evidence. Emerging technologies, such as advanced biomaterials, and global demand for cardiac surgical care, are likely to further popularise this type of bioroot Bentall. Clinical preferences are shifting towards anticoagulation-free solutions, especially for younger, small-annulus, or anti-coagulation-averse patients. The "floating" bioroot Bentall is a compelling alternative to the use of traditional mechanical prostheses, offering a balance between durability and quality of life. Prospective registries and larger head-to-head trials are now required to benchmark floating bioroot Bentall on survival, valve durability, cost-effectiveness, and patient-reported outcomes. Future research should focus on optimizing BHV durability and refining surgical techniques to further improve clinical outcomes.