What to expect from aortic root surgery

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The aorta is the largest blood vessel in humans, carrying oxygenated blood from the heart to the rest of the body.

An aortic aneurysm (AA) is an abnormal swelling in the wall of the aorta. There are two main types:

• Thoracic AAs: These occur in the part of the aorta that sits inside the chest.
• Abdominal AAs: These occur in the part of the aorta that sits inside the abdomen.

An ARA is a type of thoracic AA since it involves swelling of the aortic root — the junction where the aorta meets the heart. One of the heart’s four valves — the aortic valve — sits inside this junction. Its job is to prevent oxygenated blood from flowing back into the heart.

According to the Massachusetts General Hospital, most ARAs involve an abnormality of the aortic valve. Examples include aortic stenosis, where the valve does not open properly, and aortic regurgitation, where the valve does not close properly.

Aortic root surgery types

ARS repairs or replaces the aortic root. There are two types of surgery:

• Composite aortic root replacement (CARR) or “Bentall procedure”: This involves removing the damaged aortic root and replacing it with an artificial graft that attaches to the aortic valve. If necessary, surgeons may also replace a diseased aortic valve with an artificial valve.
• Valve-sparing aortic root replacement (VSARR) or “David procedure”: This is similar to CARR in that it involves removing the damaged aortic root. Unlike CARR, it also involves preserving the person’s own aortic valve. The surgeon then grafts a synthetic aortic root between the remaining section of the aorta and the aortic valve. This procedure is only suitable in cases where the aortic valve is structurally normal and the aortic regurgitation is solely due to the ARA.

When performing ARS, surgeons may opt for one of two approaches: open heart surgery or endovascular aneurysm repair (EVAR). According to the Vascular Society for Great Britain and Ireland, EVAR involves making an incision in the groin and inserting a plastic tube or stent up through the aorta and into the aneurysm, using X-rays for guidance.

When deciding whether a person is a suitable candidate for ARS, healthcare professionals will typically compare the relative risks and benefits.

The decision to proceed with surgery will largely depend on the urgency of the situation. A ruptured thoracic aneurysm is a medical emergency that requires immediate surgical intervention, whereas a small aneurysm may not require surgery unless it enlarges.

According to the American Heart Association, healthcare professionals typically recommend aortic root surgery for ARAs with a diameter of 5 centimeters (cm) or more.

People at increased risk of surgical complications may reserve surgical intervention for ARAs measuring at least 6 cm. However, surgery may be necessary for ARAs smaller than 5 cm across if the person is experiencing symptoms or has an underlying condition that increases the risk of an aortic rupture.

The National Heart Lung and Blood Institute (NHLBI) lists some general risks associated with heart surgery. These include:

• irregular heartbeat (arrhythmia)
• bleeding
• blood clots, which may lead to stroke or venous thromboembolism
• organ damage
• localized or systemic infection
• pneumonia
• memory loss, or other cognitive issues

Bentall procedure

A 2023 study of the Bentall procedure for ARA found that the procedure was associated with a mortality rate of 1.38%, indicating that almost 99% of people survived the initial surgery.

The Bentall procedure involving aortic valve replacement may pose additional risks. According to the United Kingdom’s National Health Service, these may include:

• infection
• excessive bleeding
• blood clots
• stroke or transient ischemic attack
• irregular heartbeat
• kidney problems
• wear and tear of the valve replacement

David procedure

Data from 2012 states that the mortality rate of the David procedure ranges from 1.7–2.8%. This means that the majority of people who undergo this procedure survive.

Possible risks and complications of the procedure include:

• bleeding
• blood clots
• need for another operation
• blockage in the heart
• myocardial infarction (heart attack)
• infection
• respiratory issues

These complications are uncommon outcomes of this surgery, however.

The majority of ARSs are currently open heart surgeries. Below are some general guidelines on what to expect before, during, and after open heart surgery, according to the NHLBI. The exact procedure may differ somewhat, depending on the type of ARS a person receives.

Before

Prior to surgery, a person will receive general anesthesia, which will make them unconscious and unable to feel any pain.

During

To begin the procedure, the surgeon will make a 6–8 inch incision down the center of the chest and will cut through the breast bone. They will then open up the ribcage to access the heart.

The surgeon will then connect the heart to a heart-lung bypass machine, which takes over the heart’s function. The machine diverts blood away from the heart so it no longer needs to pump blood and can remain completely still.

For ARS, the surgeon places clamps across the aorta, then removes the damaged section and stitches a synthetic graft in its place between the remaining aorta and aortic valve. In the Bentall procedure, the surgeon may also remove an aortic valve and replace it with a mechanical valve or a bioprosthetic valve made from animal tissues.

Once the surgery is complete, the surgeon will restore blood flow to the heart.

After

Following the surgery, a person will typically remain in the intensive care unit (ICU) for a day or more for observation.

During this time, a person may receive intravenous fluids and extra oxygen via a face mask or nasal prongs that fit inside the nostrils.

After leaving the ICU, a person will generally spend several days in another part of the hospital for continued observation and recovery, during which their healthcare team will closely monitor the following:

• heart rate
• blood pressure
• breathing
• the incision site

A person’s surgeon will advise them when they are ready to go home.

A 2022 longitudinal study investigated outcomes in 217 people who had undergone the Bentall procedure for ARA. According to the study, almost 99% of people survived the initial surgery. At 7-year follow-up, 93% of people were still alive, and 81% of these had not experienced a recurrence of ARA.

Information from 2012 states that the general outcome of the initial surgery using the David procedure is positive. This same information shows that in people who received surgery using the David procedure, between 87% and 98% were free from the need for reoperation in the 10–15 years following initial surgery. Between 64% and 95% were free from moderate to severe aortic insufficiency 10–15 years after surgery.

A person should contact a healthcare professional if they experience symptoms of thoracic AA. According to the British Heart Foundation, a large thoracic AA may cause the following symptoms:

• pain in the jaw, neck, chest, or upper back
• persistent cough
• hoarse voice
• difficulty breathing

However, it is important to note that a thoracic AA usually does not cause any symptoms, and healthcare professionals discover most cases during investigations for other conditions. This means people should consider speaking with a healthcare professional if they are at increased risk of developing a thoracic AA.

People who may be at a higher risk of thoracic AA include:

• older people
• people with high blood pressure or coronary heart disease
• people with a genetic condition that can increase the risk of a thoracic AA, such as Marfan syndrome

Below are some answers to common questions about ARS.

How risky is aortic root surgery?

Aortic root surgery is a type of heart surgery. As the NHLBI explains, heart surgery is associated with certain risks, including:

• arrhythmias
• bleeding
• blood clots
• organ damage
• infection
• pneumonia

Heart surgery also carries a risk of death, though this is more likely in people who are very ill prior to the surgery.

What is the life expectancy after aortic root replacement?

Life expectancy following aortic root replacement may differ according to various factors, including:

• the person’s overall health
• the type of procedure the person has
• whether the procedure involves aortic valve replacement
• the type of aortic valve replacement the person receives

A 2023 longitudinal study noted that almost 99% of people who received surgery for ARA survived the procedure, and 93% of these individuals were alive at 7-year follow-up.

A 2023 meta-analysis investigated outcomes in people undergoing ARR with mechanical valves versus bioprosthetic valves. The study found that ARR using mechanical valves was associated with better long‐term outcomes than ARR using bioprosthetic valves.

Is aortic root surgery open heart?

While less invasive, endovascular options for ARS are under investigation, the procedure currently remains an open heart operation.

Aortic root surgery (ARS) is a type of heart surgery that involves repairing or replacing the aortic root of the aorta. This is the part of the aorta that connects to the heart.

As with any heart surgery, the procedure carries certain risks, including bleeding, blood clots, and death. When deciding whether to perform ARS, doctors will compare the potential risks and benefits.

Typically, they will reserve ARS for emergencies, large aortic aneurysms, and cases where a person experiences symptoms or has an underlying medical condition that increases their risk of aortic rupture.

Factors that can affect outcomes for ARS include the person’s overall health, the type of ARS they have, and whether the procedure also involves an aortic valve replacement. Anyone who is considering surgery for an aortic root aneurysm should speak with their cardiologist for further advice and guidance.