Aortic Root Replacement

Aortic root replacement is surgery to fix an aneurysm in your largest artery, called your aorta. Specifically, it treats aneurysms in your aortic root. This is the part of your aorta that attaches to your heart. If an aneurysm grows too big or its walls get too weak, it can rupture (break open) or dissect (tear). These are life-threatening complications that surgery can prevent.

Who needs an aortic root replacement?

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

Your healthcare provider may recommend aortic root replacement if the aneurysm reaches a certain size, typically anywhere from 4 centimeters to 5.5 centimeters. You might need surgery at the lower end of this range if:

• The aneurysm is growing fast
• You have a genetic condition linked with ruptures/dissections at smaller sizes
• You have a bicuspid aortic valve
• There’s a history of aortic dissection in your biological family

The timing of your surgery also depends on other things — like your age, overall health and risk of surgery complications. Factors like unmanaged high blood pressure 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.

Types of surgery

There are two main types of aortic root replacement surgery:

• Bentall procedure: This replaces both your aortic root and your aortic valve. It can help if you have an aortic root aneurysm and a diseased valve. You receive a new valve that’s either mechanical (made of carbon and metal) or bioprosthetic (made of tissue).
• Valve-sparing aortic root replacement: This replaces your aortic root but “spares” (keeps) your native valve if it’s working well. This is often the best choice for younger people who have aortic root aneurysms associated with genetic syndromes.

Your surgeon will determine the best strategy for you based on many factors, such as the anatomy and function of your aortic valve, your age and overall health status.

Surgeons use a variety of techniques for valve-sparing surgery. Here are two common ones you might hear about:

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

How should I prepare for surgery?

Preparation is key to a successful surgery, and it starts well before your surgery day. Your healthcare provider will give you a physical exam. They may run tests like:

• Blood work to check your kidney function
• CT or heart MRI to check all parts of your aorta
• Coronary angiogram to check for plaque in your coronary arteries, which may affect the approach your surgeon uses
• Duplex ultrasound to check for plaque in your carotid arteries, which, if untreated, can raise your risk of a stroke during surgery

You’ll also talk with your provider about:

• Medicines you’re taking: Your provider needs to know which medicines (prescription and over-the-counter), supplements and herbs you’re using. They may ask you to stop taking some as you prepare for surgery. Ask for written instructions to take home.
• Medical conditions: You’ll need to manage conditions like high blood pressure and COPD before your surgery. This may involve taking medicines or other treatments.
• How you’re feeling: If you have a cold, flu, herpes outbreak or any other illness, tell your provider. They’ll make sure you have surgery when you’re healthy enough for it.
• Smoking or tobacco use: You shouldn’t smoke or use tobacco products for at least one month leading up to your surgery. Talk with your provider about resources to help you quit.

Your provider will give you detailed instructions for your surgery day, including when to stop eating/drinking and any medicines you should take.

What happens during aortic root replacement?

To perform an aortic root replacement, your surgeon will:

1. Give you anesthesia: This medicine puts you into a deep sleep so you won’t feel pain.
2. Make a cut (incision) in your chest: This step is called a median sternotomy. It allows your surgeon to access your heart.
3. Connect you to a cardiopulmonary bypass machine: This machine does the work of your heart and lungs during surgery.
4. Remove the aneurysm: Your surgeon removes the part of your aorta that’s weak and bulging. The aneurysm may only affect your aortic root. Or it may include more of your ascending aorta (the part that curves upward from your heart).
5. Insert a graft: Your surgeon replaces the aneurysm with a tube called a graft. This functions as a new artery. It’s made of collagen-coated polyester.
6. Keep or replace your aortic valve: This step varies by surgery type. With the Bentall procedure, you receive a new valve. Your surgeon connects it to the graft. If you have valve-sparing aortic root replacement, your surgeon connects your natural valve to the graft.
7. Attach your coronary arteries: These arteries supply blood to your heart. They begin at your aortic root. Your surgeon attaches them to the graft.
8. Close the incision: Your surgeon takes you off the bypass machine. They close your incision with stitches. 

The Bentall procedure takes about four to five hours. Valve-sparing aortic root replacement is about four to six hours.

What are the potential benefits and risks of this procedure?

A major benefit of aortic root replacement is that it can prevent a life-threatening aneurysm rupture or dissection. Plus, both types of surgery (Bentall and valve-sparing) are successful for most people.

Which type has more benefits for you depends on how well your valve is working and any underlying conditions you have. For example, some research shows people with Marfan syndrome have better outcomes with valve-sparing surgery than with the Bentall procedure.

But like any major surgery, aortic root replacement comes with some risks. 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 if you have other serious health problems, including:

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

Risks vary by person and increase with age. Talk with your provider about your risks and how to manage them. 

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. Most people need to stay in the hospital for about one week total.

While you’re in the hospital, you’ll receive:

• A catheter to help you pee
• A tube through your nose and stomach that drains fluids
• Blood-thinning medication (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 medicine to ease your recovery

Follow your provider’s guidance and take things slow. This healing time helps 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 is the recovery time?

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.

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.

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. Tissue valves last at least 10 to 15 years in most people but then may need to be replaced.

If you have valve-sparing aortic root replacement, your natural aortic valve may last for life. But you may need another surgery at some point to get a new valve. It depends on your anatomy and other medical conditions.

When should I call my healthcare provider?

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

Incision issues, like:

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

Signs of a surgery complication, like:

• Chest pain or shortness of breath when you rest
• Swelling in your legs or trouble moving them
• Dizziness, fainting or extreme tiredness
• Coughing up blood or yellow/green mucus
• Chills or fever
• Blood in your poop

When to seek emergency care

If you have an untreated aortic aneurysm, you’re at risk of rupture or dissection. Call 911 or your local emergency number if you have:

• Sudden, severe pain in your chest or upper back (it may feel like something is tearing or ripping inside you)
• Chest pain or discomfort of any kind
• Clammy, sweaty skin
• Coughing or hoarseness
• Trouble breathing
• Dizziness or fainting
• Fast heartbeat
• Nausea and vomiting