Aortic Root Aneurysms: Pathophysiology, Indications for Intervention, and Contemporary Surgical Management Including Minimally Invasive Approaches

Aortic root aneurysms are a heterogeneous form of thoracic aortic disease in which wall pathology, root geometry, valve function, and patient phenotype jointly determine clinical risk and surgical strategy. PubMed/MEDLINE was searched for publications from January 2020 through 30 June 2026, prioritizing contemporary evidence. Current evidence supports assessment beyond maximal diameter alone, integrating enlargement pattern, growth behavior, valve morphology and competence, underlying aortopathy, and multimodality imaging to refine surveillance and timing of intervention. Once surgery is indicated, reconstruction must be tailored to root anatomy, cusp quality and repairability, patient characteristics, and expertise. Composite root replacement remains appropriate when valve preservation is unsuitable, whereas valve-sparing approaches can preserve native valve function in selected patients when durable reconstruction is achievable. Minimally invasive access may reduce selected perioperative burdens, but evidence is predominantly observational and does not establish superiority over conventional sternotomy. In acute aortic syndromes, the extent of root reconstruction must also reflect anatomical disruption and immediate physiological risk. Emerging technologies may broaden treatment options, but their evidence base and clinical maturity remain heterogeneous. Contemporary management should therefore match the timing, extent, and type of intervention to the individual root phenotype while preserving procedural safety and durable valve function.