**Conflict of interest**

None.

**4.3. Reoperation of the aortic root**

130 Structural Insufficiency Anomalies in Cardiac Valves

artery length, and infection.

tion in the Freestyle group [21].

operative and with long-term follow-up studies.

encountered.

**5. Conclusion**

aortic root pathology.

Structural failure of the root, pseudoaneurysms, or infection may necessitate redo aortic root replacement. This is an operation that typically carries a higher risk of mortality and morbidity. Some special considerations include: calcified homografts or stentless valves, coronary

In patients with a heavily calcified neo-aortic wall it is often extremely difficult to dissect out the wall and redo the root as it becomes very adherent to the adjacent structures and pulmonary artery and coronaries can be injured. Replacing just the aortic valve within the calcified root is an option. With the advent of transaortic valve implantation (TAVI), this may be an option in high risk patients. El-Hamamsy et al. compared the Freestyle graft with homograft aortic root replacement in a prospective, randomized trial, and showed an improved age of survival, lower rate of reoperation, and echocardiographically less signs of valvular deteriora-

There can be difficulty with mobilizing the coronary buttons and placing them in into the new root or they can be damaged. The Cabrol technique should then be deployed, where a graft is sutured end to end to both the right and left coronary buttons then sutured side to side to the aorta. A second option is to place an interposition vein graft between the coronary buttons and the graft. This is the author's preferred method as we find the grafting to be easier. Lastly bypass-grafting can be done with ligation of the coronary arteries. This is typically a last resort when bleeding and technical difficulties with the anastomosis are

Infected roots pose a major problem because of the amount of debridement and reconstruction that is required. The same surgical principles apply of removal of all infected and foreign tissue. Results have been promising using homograft replacements as demonstrated in peri-

The anatomic complexity and serious pathology that affect the aortic root challenge the cardiac surgeon. In the 61 years since De Bakey and Cooley first replaced an ascending aneurysm with the aid of cardiopulmonary bypass, a number of surgeons' devised innovative steps to improve patient outcomes. Leaders in the field of cardiac surgery such as Bono, Bentall, Yacoub, and David have contributed greatly to our surgical armamentarium for treatment of

The design of the De Paulis Valsalva graft is another great addition to the surgeon's arsenal and reinforces the need to continue analyzing and improving surgical techniques based on the dynamic physiologic environment of the aortic root during aortic valve sparing procedures. While it is common to hear surgeons refer to aortic root replacements as a "Bentall," the procedures currently employed have undergone an evolution, enough so that what is done now does not resemble the aortic inclusion and side-to-side coronary anastomosis technique.
