Aortic Root Replacement

What is aortic root replacement surgery?

Aortic root replacement surgery fixes an aneurysm in the part of your aorta that attaches to your heart. An aneurysm is a weak spot in a blood vessel wall. Aneurysms can dissect (tear) or rupture and cause life-threatening internal bleeding. Aneurysm surgery can save your life by preventing rupture or dissection.

Aortic root replacement surgery may replace both your aortic root and your aortic valve. Or, it may replace your aortic root but leave your valve. The type of surgery you have depends on many factors including the health of your aortic valve.

What are the different types of aortic root replacement surgery?

There are two main types of aortic root replacement surgery. One is called aortic root replacement (ARR). The other is called valve-sparing root replacement (VSRR). There are benefits and risks to both types.

Aortic root replacement (ARR)

Aortic root replacement (ARR) replaces your aortic root plus your aortic valve. It’s also called the Bentall procedure. It’s for people who have an aortic root aneurysm plus aortic valve problems. ARR can be helpful if you have aortic valve regurgitation (leaky valve) or calcification (hardening).

The main benefit of ARR is that you probably won’t need another surgery down the road to fix your valve. It takes care of your aneurysm and your valve all at once.

You may receive a mechanical valve with this procedure. People with a mechanical valve need to take blood thinners (anticoagulants). Risks include blood clots and bleeding.

Valve-sparing root replacement (VSRR)

Valve-sparing root replacement (VSRR) is a good choice if your aortic valve is working well. For example, you don’t have severe regurgitation or calcification. It’s often the best choice for younger people who have aortic root aneurysms associated with genetic syndromes.

VSRR replaces your aortic root but not your aortic valve. VSRR is further divided into two types named after the doctors who developed them.

• The Yacoub procedure involves remodeling your aortic valve. It’s better for people who are older and whose aneurysms aren’t linked to a genetic syndrome.
• The David procedure involves reimplantation of your aortic valve. It’s more common than the Yacoub procedure but also more technically complex. It’s better for people who are younger and have a genetic syndrome or bicuspid aortic valve.

Both types have excellent long-term results and a low risk of valve-related complications. Your surgeon chooses the type of procedure based on your medical profile and age.

The main benefit of VSRR is that you don’t need to be on blood thinners for the rest of your life. You may have a lower risk of a stroke or endocarditis. You can keep your valve for many years as long as it keeps working well.

Risks of VSRR include the possibility of another surgery down the road to repair your valve. This may be needed if you have aortic regurgitation that gets worse over time.

What is the anatomy of my aortic root?

Your aortic root is the first part of your aorta that attaches to your heart. Your aorta is the largest artery in your body. It’s shaped like a shepherd’s crook. The “handle” curves upward out of your heart. Your aortic root is the very start of the handle. It’s connected to your heart by a tough, fibrous ring called the aortic annulus (also known as the aortoventricular junction).

Your aortic root gives rise to your ascending aorta. This is the upward curve of the “handle.” Some aneurysms affect both your aortic root and your ascending aorta. Your ascending aorta leads up to your aortic arch, which is the peak of the curve. Your descending aorta is the part after the arch, which you can picture as the straight stick of the shepherd’s crook. It travels down through your chest and leads to your abdominal aorta (the part in your belly).

The aortic root contains your aortic valve. It’s also where your coronary arteries begin. Your surgeon may mention your aortic sinuses (also called the sinuses of Valsalva). These are gentle bulges in your aortic root that give rise to your coronary arteries.

All parts of your aortic root are elastic and flexible when you’re a child. But they become less flexible as you get older. This loss of elasticity affects how they move and how well your aorta can function.

Because your aortic root is so complex, surgery on it is also complex. But in skilled and experienced hands, your aortic root can be made healthy again.

Who needs an aortic root replacement?

People who have an aneurysm at risk of rupture or dissection may need an aortic root replacement. Sometimes an aortic root aneurysm is caused by aging and changes to your aorta over time. Genetic disorders like Marfan syndrome and Loeys-Dietz syndrome also cause aortic aneurysms. Such disorders can lead to fatal aneurysms in younger people.

People with Marfan syndrome who don’t receive treatment are at risk of aneurysm rupture or dissection. The average age of death among this group is 32; with surgery to repair aneurysms, life expectancy is much longer. Problems with the aortic root cause 60% to 80% of these deaths. If others in your family have Marfan syndrome, you face a higher risk even with smaller aneurysms. It’s essential to talk with your provider about your personal risk and the best timing for treatment.

When does an aortic root need to be replaced?

Guidelines for aortic root replacement are based on your aneurysm size plus other risk factors for aortic dissection. You may need surgery when your aortic root aneurysm reaches the following diameters:

• 5.5 centimeters if you have no genetic conditions or other risk factors.
• 5.0 centimeters if you have Marfan syndrome.
• 4.5 centimeters if you have Marfan syndrome and a family history of aortic dissection, aneurysm growth of more than 3 millimeters per year, severe aortic or mitral valve regurgitation, or plans to become pregnant.
• 5.0 centimeters if you have a bicuspid aortic valve and other risk factors. These include hypertension, aortic valve regurgitation or rapid aneurysm growth.

Each person has a unique medical history and particular needs. So, the timing varies based on other factors like your age, overall health and risk of surgery complications. Factors like uncontrolled hypertension and smoking can make an aneurysm grow faster. Talk with your provider about your personal risks and how to choose the safest time for your surgery.

How serious is aortic root replacement?

Aortic root replacement is a major surgery. It involves opening your chest and fixing problems with your heart. This surgery can save your life by reducing your risk of an aortic aneurysm rupture or dissection. Aortic root replacement has been performed for decades. Surgeons continue to refine techniques to give you the best outcome.

What happens before aortic root replacement surgery?

Preparation is key for a successful surgery. Your provider will give you a physical exam, and you’ll also go to your dentist for a check-up. Your provider may run the following pre-operative tests:

• Blood work to check your kidney function.
• CT or heart MRI to check all parts of your aorta. Sometimes other problems with your aorta, like aortic valve disease, can be fixed during the same surgery.
• Coronary angiography to check on the health of your coronary arteries. Your surgeon needs to know if you have atherosclerosis to plan the best surgical approach for you.
• Duplex ultrasound to check the health of your carotid arteries. Untreated problems with your carotid arteries can raise your risk of a stroke during surgery. If you’re over age 65 or have peripheral artery disease, this test is vital for you.

You’ll also talk with your provider about:

• Medicines you’re taking. Your provider needs to know what drugs, supplements and herbs you’re using. These include prescription and over-the-counter medicines. Your provider may ask you to stop taking some medicines as you prepare for surgery. Ask for written instructions so everything is clear for you at home.
• Medical conditions. You’ll need to control conditions like high blood pressure before your surgery. You may need to take antibiotics if you have chronic bronchitis.
• How you’re feeling. If you have a cold, flu, herpes outbreak or any other illness, tell your provider.
• Smoking or tobacco use. You should not smoke or use tobacco products for at least one month leading up to your surgery. Talk with your provider about available resources to help you quit.

Your provider will give you detailed instructions for the day of your surgery. Follow them closely. Common guidelines include:

• Not drinking anything after midnight the night before your surgery. That includes water.
• Taking certain drugs the morning of your surgery.
• Planning for someone to drive you to the hospital and pick you up after recovery.

Be sure to ask your provider if you have any questions.

What happens during aortic root replacement surgery?

Your care team will help make you comfortable and give you anesthesia to put you to sleep. You’ll be put on something called cardiopulmonary bypass. This is a heart-lung machine that does the work of your heart and lungs during surgery. Your care team may also use deep hypothermic circulatory arrest (DHCA) to pause your blood circulation. These machines help control your blood flow during your surgery.

Aortic root replacement involves several steps:

1. Median sternotomy. This is a vertical incision in your chest. Your surgeon will divide your sternum (breastbone) to access your heart.
2. Aneurysm removal. Your surgeon will remove your aortic aneurysm. This is the part of your aorta that is bulging due to weakened arterial walls. The aneurysm may only affect your aortic root, or it may include more of your ascending aorta.
3. Graft insertion. Your surgeon will replace the aneurysm with a tube called a graft. This graft functions as a new artery. It’s made of collagen-coated polyester.
4. Aortic valve replacement or sparing. This step depends on the type of procedure you have. Aortic root replacement (ARR), also known as the Bentall procedure, involves replacing your valve. Your new valve will be either biological or mechanical. If you have valve-sparing root replacement (VSRR), your aortic valve will be spared (kept). Your surgeon will tell you before your surgery if you’ll have the David method (more common) or the Yacoub method.
5. Coronary artery attachment. Your surgeon will attach your coronary arteries to your new graft.
6. Closure. Your surgeon will close the incision with stitches.

The surgery time for ARR is about four to five hours. The surgery time for VSRR is about four to six hours.

What happens after aortic root replacement surgery?

After your surgery, you’ll spend several days in the intensive care unit (ICU). You’ll then move to a regular hospital room. Your total hospital stay will be about one week.

While you’re in the hospital, you receive:

• A urinary catheter to help you pee.
• A tube through your nose and stomach that drains fluids.
• Blood-thinning medication (anticoagulants in some but not all people).
• Compression socks that help prevent blood clots in your legs.
• A breathing machine to help support your lungs.
• Pain medication to ease your recovery.

Follow your provider’s guidance, and take things slow. This healing time is essential for helping you get back to normal.

You won’t be able to drive until your provider gives you the OK. So be sure to have someone ready to drive you home.

What are the advantages of aortic root replacement surgery?

Elective (planned) aortic root replacement surgery can prevent an aneurysm rupture or dissection. It helps you avoid a medical emergency that can be fatal.

Emergency surgery to repair a dissected or ruptured aortic root aneurysm can save your life.

What are the risks or complications of aortic root replacement surgery?

Aortic root replacement is a major surgery. Like any major surgery, it carries risks and complications. These include:

• Bleeding.
• Blood clots.
• Breathing problems.
• Heart attack or stroke.
• Infection in the graft.
• Infection in the lungs, urinary tract or belly.
• Kidney failure.
• Nerve damage.

Any open surgery is riskier for people with other serious health problems, including:

• Heart disease.
• Kidney failure.
• Lung disease.
• History of a stroke.

Risks vary based on the person. Risks also increase with age. Talk with your provider about your individual risks and how to manage them.

What is the recovery time after aortic root replacement surgery?

Full recovery from aortic root replacement surgery takes at least six to 12 weeks. For some people it can take two to three months. This includes your time in the hospital, at home and in cardiac rehab. Medicare and most insurance companies cover up to 12 weeks of cardiac rehab. It’s worth your time to use this service. Rehab improves your strength and quality of life after heart surgery. You’ll also be able to meet people who are going through the same thing.

After you recover, you’ll go for regular follow-ups so your provider can check your heart health. You’ll have routine imaging including echocardiograms (echos) and CT scans. These tests help make sure your aorta is working as it should.

When can I go back to my usual activities?

Your surgeon will tell you when it’s safe to return to your usual activities. In general, you shouldn’t drive or lift heavy objects for six weeks. You may be able to return to work after six to eight weeks, but only if your job isn’t physically demanding. You’ll need to wait longer for physically demanding jobs.

How successful is aortic root surgery?

Both types of surgery (ARR and VSSR) are successful for most people. Research shows that 10 years after aortic root surgery, 86% to 90% of people don’t need another surgery. The risk of reoperation is higher for people who have Marfan syndrome.

ARR has become a routine procedure in most hospitals around the world. VSRR, especially the David method, is less widespread. This is because VSRR is very complex and requires specialized training and experience. VSRR surgeries have excellent long-term results and low rates of valve-related complications.

What is the aortic root replacement survival rate?

Aortic root surgery (both ARR and VSRR) have excellent survival rates. About 98% to 99% of people survive the surgery.

How long does an aortic root replacement last?

Aortic root replacement is a durable and long-term solution for aortic root aneurysms. How long the valve lasts depends on the type of valve you receive. Mechanical valves last for the rest of your life, but you need to take blood thinners. Biologic valves last at least 10 years in most people but then may need to be replaced.

If you have VSRR, your natural aortic valve may last the rest of your life. But you may need another surgery at some point to get a new valve. It depends on your anatomy and other medical conditions.

Before your surgery, you’ll have pre-operative imaging tests. These tests will help your surgeon predict the durability of your specific surgery. Talk with your surgeon before surgery and make sure you understand your long-term outlook.

When should I see my healthcare provider?

Pay attention to your body and how you’re feeling as you recover. Call your provider right away if any of these problems come up:

Incision (surgical wound) problems:

• Redness, pain, warmth or swelling.
• Blood or clear fluid soaking through your bandage.
• Green or yellow drainage.
• Edges of your incision coming apart.

Other problems:

• Chest pain or shortness of breath even when you rest.
• Swollen legs or inability to move your legs.
• Dizziness, fainting or extreme fatigue.
• Coughing up blood, or coughing up yellow or green mucus.
• Chills or fever.
• Blood in your poop.

These problems may signal a surgery complication. Your provider will discuss how you’re feeling and may bring you in to get checked.

When should I call 911?

If you have an untreated aneurysm, you’re at risk of rupture or dissection. Call 911 if you have the following symptoms:

• Sudden, severe pain in your chest or upper back. It may feel like something is tearing or ripping inside you.
• Chest pain of any kind.
• Clammy, sweaty skin.
• Coughing, feeling hoarse or having trouble breathing.
• Dizziness.
• Fainting.
• Fast heartbeat.
• Nausea and vomiting.
• Shortness of breath.

A note from Cleveland Clinic

Aortic root replacement is a life-saving surgery. It reduces your risk of a fatal aneurysm rupture or dissection. Some people need it in their 20s or 30s while others need it much further down the road. But no matter the timing, heart surgery can feel scary and overwhelming. Just remember that this surgery might be your “first,” but heart surgeons are trained to do it every day. Your recovery is your surgeon’s top priority. Talk with your healthcare team about all your questions and concerns. Share your thoughts and emotions with trusted family and friends. And make yourself a top priority as you recover so you can get back to your usual routine feeling better than ever.