Conservative surgical treatment: The present and the future.

Conservative management of aortic insufficiency relies on three physiological strategies preserving native valve function and root dynamics: aortic valve repair; the Ross procedure; and personalized external aortic root support (PEARS). Aortic valve repair is the cornerstone of conservative surgery for dystrophic bicuspid and tricuspid aortic insufficiency, with or without aneurysm, as it restores normal life expectancy while reducing lifelong prosthetic valve-related complications. Standardized techniques combining calibrated annuloplasty with systematic cusp effective height assessment have improved reproducibility and durability, leading to a Class I recommendation in the 2025 European guidelines. Yet, only one in five patients benefits from repair, underscoring the need for wider adoption. The Ross procedure, using the pulmonary autograft as a living valve substitute, offers a quality of life and life expectancy similar to the general population, with fewer thromboembolic or bleeding events than mechanical aortic valve repair and lower reoperation rates than bioprostheses in selected young adults. Tissue-engineered living implants aim to reproduce these results, but are not yet available clinically. PEARS provides a preventive off-pump approach for patients with root aneurysm without valve dysfunction. A three-dimensional customized macroporous mesh stabilizes the aortic root while maintaining native valve physiology and avoiding coronary reimplantation. Together, these three techniques redefine modern aortic valve surgery by offering individualized, durable and physiological alternatives that preserve native tissue, restore normal valve dynamics and achieve normal quality of life and long-term survival.