Despite the technically challenging nature of valve-sparing root replacement, restoration of aortic valve competence can be achieved through a complete understanding of the aortic root anatomy and pathophysiology. In this review, we discuss the physiology of normal aortic root function as well as pathophysiologic mechanisms contributing to aortic valve incompetence. Preoperative planning for valve-sparing root replacement is discussed, including the use of imaging to guide surgical decision-making. Pitfalls and pearls of the critical technical steps for both valve-sparing root replacement and repair of both tricuspid and bicuspid aortic valves are provided. Finally, current evidence guiding best practices in valve-sparing root replacement and aortic valve repair is presented to support decision-making for patient selection.
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