**2. Historical perspective**

The first successful replacement of a fusiform ascending aortic aneurysm was reported by Cooley and De Bakey in 1956 [1]. That first report was made possible thanks to the introduction of cardiopulmonary bypass to aortic aneurysm surgery. Following, several surgeons forged ahead and described similar experiences with similar pathologic entities.

therefore cause valve-regurgitation. In other patients, the aortic valve leaflets may be abnormal because of bicuspid morphology and the disease is associated with an enlarged ascending aorta. When the primary indication to operate on the patient is the aortic valve disease or myocardial revascularization, the ascending aorta is usually replaced very liberally (this means if the diameter is larger than 4.5 cm). Another situation that calls for the repair of the aortic root and ascending aorta is the patient that presents with severe aortic valve stenosis (either bicuspid or tricuspid aortic valve) and with post-stenotic dilation of the ascending aorta. In this category of patients, if the sinotubular junction is maintained and the aortic root diameter at the level of sinuses of Valsalva does not exceed 4 cm, it is generally accepted that a separate aortic valve replacement and supracoronary replacement of the ascending aorta with

Contemporary Surgical Options for the Aortic Root http://dx.doi.org/10.5772/intechopen.75816 123

During the last decade, the authors have been increasingly aggressive in the replacement of the complete ascending aorta and base of the aortic arch using a short period of antegrade

Contemporary surgical options for the aortic root include either a full aortic root replacement (biological or mechanical), or valve sparing aortic root replacement. Different graft options

The aortic root can be replaced with either a synthetic material (usually Dacron) or a biologic prosthesis. Biologic options come in the form of xenografts or homografts. Synthetic graft options includes expanded poly (ethylene terephthalate) (Dacron) or poly(tetrafluoroethylene) (ePTFE), and represent the most widely employed vascular substitutes in cardiovascular surgery. Dacron grafts can come in a straight tubular shape or in a specifically designed form

Xenografts can come in the form of stented or stentless valve. Some of the stentless valves present as a full root products and can either be implanted as a full root replacement and/or as a valve replacement alone. The stented valves may be used for valve replacement alone, or

This third-generation device presents as the complete porcine aortic root with thin polyester covering of the septal myocardium. The tissue is glutaraldehyde fixed using the physiologic root pressure technique: there is zero net pressure applied to the valve cusps to preserve collagen crimp while the aorta is distended to normal configuration. The graft may be implanted as a valve replacement in the subcoronary position, as an inclusion root cylinder, or as a full

cerebral perfusion, performing the distal anastomosis without aortic cross clamp.

that, on implantation and pressurization, generates pseudosinuses of Valsalva.

may be composed to any graft type in order to be served for full root replacement.

and/or valve options exist and are further discussed below.

**3.1. Graft and valve options for aortic root surgery**

Some options for stentless valves include the following:

*3.1.1.1. Freestyle™ porcine aortic root bioprosthesis (medtronic)*

a prosthetic graft can be performed.

*3.1.1. Xenografts*

aortic root replacement.

Handling of the aortic root, below the sinotubular junction was first reported in 1964, when Wheat reported his team's efforts to replace the entire ascending aorta [2]. Although the procedure performed may not have involved the entire aorta as the title claimed, its legacy was secured as a description of how to handle pathology extending proximal to the coronary ostia. Their approach to the displaced coronary ostia was to resect the aorta 1.5–2 cm proximal to this level, while leaving a tongue of tissue surrounding the two coronary takeoffs. In this way, they maintained the integrity of the ostia and ensured the sutures were far enough from the coronary arteries.

While others continued to work tirelessly, the group at Oregon, including Drs. Herr and Starr, were diligently at work devising mechanical valves that would eventually be used for Bentall's historic procedure [3, 4]. In 1968, they published their ongoing clinical experience and engineering progress. Their ingenuity to use a composite valve-graft prosthesis was a major step in the progression of aortic root surgery, and the composite valve-graft, whether using a mechanical (as originally done) or tissue valve, is still considered the gold standard today [5].

Following, new concepts evolved for sparing the aortic valve and replacing the aortic root only. The first was developed by Sir Yacoub, and had been used in his practice since 1979 [6, 7]. The procedure, which he designed, later became referred to as the "remodeling technique." The functional focus was to preserve the native valve, while recreating the aortic sinuses. This goal was achieved by fashioning a scalloped Dacron® graft such that three tongues extended to replace the intrinsic sinuses. Interposed between these three extensions, native tissue was left intact at the attachment of the cusps. Once the graft was attached, the coronary arteries would be mobilized and anastomosed to the neoaorta.

In the late 1980s, David and his colleagues at the University of Toronto developed an alternative class of valve-sparing procedures [8]. Their procedure went through numerous iterations and variations, but classically the technique became referred to as the "reimplantation technique." [9, 10] This approach had the benefit of stabilizing the aortic annulus by sewing the native valve directly into a Dacron® graft of a fixed circumference.
