The natural history of patients with aortic regurgitation (AR) is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival of these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery (AVP) has attracted a great deal of attention as it has significant survival benefit over replacement. Nonetheless, AVP has not been widely adopted due to the complexity of its technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, AVP has increasingly been performed with better outcomes, and therefore earlier indication for surgical intervention in cases of AR has been considered. Recent advances in AVP include repair-oriented classification of the etiology of AR, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of AVP, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of AVP in surgical treatment of AR in the near future.
