Toward total endovascular repair of the aortic root: What does the optimal device require

Endovascular management of complex proximal ascending aorta, aortic valve, and aortic root pathology represents the final frontier of aortic intervention. The Endo-Wheat and Endo-Bentall procedures aim to replicate the principle of surgical replacement by combining an endograft, a transcatheter valve, and a strategy for maintaining coronary perfusion with or without coronary revascularization. A new anatomical definition of zone 0 has been recommended by several authors to facilitate standardized reporting in the proximal ascending aorta and aortic root. Multiple feasibility studies have demonstrated variable anatomical suitability for Endo-Wheat and Endo-Bentall procedures depending on the aortic pathology studied, with key limitations including coronary size, height, and angulation, as well as a dynamic, short, and nonuniform proximal landing zone. Early preclinical studies, first-in-human experiences, and case series have demonstrated clinical feasibility using different combinations of endograft and transcatheter aortic valve systems, with various arterial accesses, with or without extracorporeal cardiopulmonary bypass support. However, the collective sample size remains very small, with carefully selected cases, heterogeneous techniques, and short-term follow-up. Ultimately, an optimal Endo-Wheat or Endo-Bentall device will require a dedicated design addressing considerations involving the proximal and distal landing zones, aortic valve, coronary perfusion, mechanism of deployment, access, and device durability. Ongoing innovations and clinical evaluations in these areas will ultimately determine the general applicability and reproducibility of this technology in patients with proximal thoracic aortic disease.