What is the PEARS procedure?
The PEARS procedure, which stands for Personalised External Aortic Root Support, is a surgical technique designed to reinforce the aortic root; the section of the body's largest artery nearest to the heart, when it has become dangerously widened. Unlike conventional operations that involve cutting out and replacing the diseased portion of the aorta, PEARS works from the outside.
A bespoke mesh sleeve, known as the ExoVasc® graft, is wrapped around the exterior of the aortic root to prevent further enlargement and reduce the risk of a life-threatening tear known as an aortic dissection.
The mesh is not an off-the-shelf device. Each one is individually manufactured using detailed computed tomography (CT) scans of the patient's own aorta, producing a support that matches the precise three-dimensional anatomy of that individual. The implant is made from a pliable, knitted polyester material, the same kind of durable fabric used in vascular grafts for decades. Once in place, it acts rather like a corset, holding the aorta at its current size and, in some cases, gently reducing it slightly to improve the function of the aortic valve.
A defining feature of the PEARS procedure is that the surgeon does not open the heart or the aorta itself. In most straightforward cases, the operation is performed on a beating heart without the need for a heart-lung machine (cardiopulmonary bypass). This means the patient's own heart continues to pump blood throughout the body while the surgeon positions and secures the external support.
Why would I require the PEARS procedure?
The procedure is principally recommended for individuals whose aortic root has dilated beyond a safe diameter, a condition referred to as an aortic root aneurysm. This widening is most commonly associated with connective tissue disorders such as Marfan syndrome, Loeys-Dietz syndrome, and vascular Ehlers-Danlos syndrome, as well as certain congenital conditions including bicuspid aortic valve disease. In these patients, the structural proteins that give blood vessels their strength and elasticity are compromised, causing the aortic wall to stretch progressively over time.
If left untreated, an enlarging aortic root carries a serious risk of dissection; a tear in the inner layer of the vessel wall that allows blood to split the layers apart, or outright rupture. Both events are catastrophic and frequently fatal. The PEARS procedure is offered as a preventative measure when the aortic root reaches a diameter at which the risk of these complications becomes unacceptable, typically around 4.5 to 5.0 centimetres in patients with Marfan syndrome.
The operation may also be considered for women with aortic root aneurysms who are planning a pregnancy, as the cardiovascular changes of pregnancy increase the risk of dissection. Because PEARS preserves the native aortic valve and avoids the need for lifelong blood-thinning medication, it can be an attractive option for younger patients.
Is the PEARS procedure a recent innovation in heart surgery?
The procedure was first performed in 2004. It was conceived by Tal Golesworthy, a British chartered engineer who himself lives with Marfan syndrome, in collaboration with Professor Tom Treasure, a distinguished cardiothoracic surgeon. Faced with the prospect of conventional aortic root replacement, Golesworthy applied his engineering expertise to design an alternative that would support his own aorta rather than excise it.
Since those early operations, the technique has been refined and progressively adopted. It received a Health Technology Appraisal from the National Institute for Health and Care Excellence (NICE). The ExoVasc® implant is now in use at more than forty specialist cardiac centres across the United Kingdom, Europe, Australia, Singapore, and New Zealand, with over several hundred procedures performed to date.
How long does the operation for the PEARS procedure take?
The PEARS procedure typically takes between two and three hours, with an average operating time of approximately two and a half hours. This is notably shorter than conventional aortic root replacement operations, which commonly require four to seven hours under anaesthesia. The reduced duration is largely attributable to the fact that the surgeon does not need to stop the heart, open the aorta, or reconnect coronary arteries.
In the majority of straightforward cases, cardiopulmonary bypass is avoided entirely. A small proportion of patients with more complex anatomy, such as unusual coronary artery arrangements, may require partial bypass support, but even then, the bypass times are minimal compared with traditional surgery.
How long is the healing process post-operation?
Following surgery, patients typically spend approximately twenty-four hours in the intensive care unit, though this can extend to two or three days in more complex cases. The average length of stay in hospital is around six to seven days, with most patients discharged within a week of their operation. This represents a somewhat faster recovery trajectory than conventional root replacement, where hospitalisation often extends beyond ten days.
Once at home, patients are generally advised to avoid strenuous activity and heavy lifting for approximately six to eight weeks, allowing the breastbone, which is opened during the procedure, to heal fully. Cardiac rehabilitation is recommended and most individuals return to their normal daily activities within two to three weeks of discharge, with full physical recovery expected by around twelve weeks. Regular follow-up imaging, usually through echocardiography or CT scanning, is conducted to monitor the stability of the aortic root over subsequent years.
Is life expectancy extended by the PEARS procedure?
Without treatment, the natural history of aortic root aneurysm in connective tissue disorders is poor. Historical data from the 1970s recorded a median survival of approximately forty years for men and forty-eight years for women with Marfan syndrome, with aortic dissection being the leading cause of premature death. Modern surveillance and surgical intervention have transformed this outlook dramatically.
Published outcomes for the PEARS procedure, with follow-up extending to nearly nine years, report no peri-operative deaths, strokes, or heart attacks in the early patient cohorts. Aortic dimensions have remained stable over time, and the rate of re-operation has been remarkably low; above ninety-five per cent freedom from re-operation, with only two documented re-operations across hundreds of procedures performed worldwide. While longer-term data over twenty or thirty years are still accruing, current evidence indicates that survival following PEARS is comparable to that of age-matched individuals in the general population, suggesting that the procedure effectively normalises life expectancy for suitable patients.
How is quality of life improved after the PEARS procedure?
Quality of life after PEARS is enhanced in several important ways. Because the native aortic valve is preserved and not replaced with an artificial prosthesis, patients avoid the long-term burdens associated with mechanical valves, principally the need for lifelong anticoagulation therapy.
Warfarin, the most commonly prescribed blood thinner, requires regular blood monitoring and dietary vigilance, and carries an inherent risk of bleeding. By sidestepping this requirement, PEARS allows patients; many of whom are young and physically active, to pursue sport, travel, and pregnancy without the constraints of anticoagulation.
Additionally, the procedure can correct mild to moderate aortic regurgitation (leakage of the aortic valve) by deliberately fitting a marginally smaller mesh, which gently reduces the aortic root diameter and helps the valve leaflets to close more effectively. This can alleviate symptoms such as breathlessness and fatigue that arise from valve leakage.
The shorter operative time, avoidance of cardiopulmonary bypass in most cases, and swifter convalescence all contribute to a less arduous recovery compared with traditional surgery. Patients report returning to work, exercise, and family life sooner, and the psychological reassurance of knowing that the risk of aortic dissection has been substantially mitigated cannot be overstated.
For many individuals living with the daily anxiety of a known aneurysm, the PEARS procedure offers not only a physical safeguard but also meaningful peace of mind.
Which specialist performs the PEARS procedure?
The PEARS procedure is performed by consultant cardiothoracic surgeons who have received specialist training in aortic root surgery and the specific technical requirements of the PEARS technique. Cardiothoracic surgeons specialise in operative treatment of diseases affecting organs inside the chest, particularly the heart and lungs. Within this specialty, only a subset of surgeons focus their practice on the aorta and its related structures, and an even smaller number maintain active programmes performing the PEARS procedure.
Not every cardiothoracic centre offers PEARS, as the operation requires both surgical expertise and access to the bespoke manufacturing process for the ExoVasc® implant. The procedure is available at a limited number of tertiary referral centres with dedicated aortic teams. Patients seeking this treatment are typically referred to these specialised hospitals, where multidisciplinary teams evaluate suitability for the procedure.
The surgeon performing the operation should have substantial experience in valve-preserving aortic surgery and familiarisation with the PEARS workflow, from pre-operative CT imaging through to implantation. Because the procedure involves external placement of a support device rather than internal reconstruction of the aorta, the surgical approach differs meaningfully from open-heart surgery.
Patients are advised to inquire about their surgeon's individual caseload and outcomes with PEARS when considering treatment options. Referral to a centre that performs a higher volume of PEARS procedures may offer advantages, as surgical outcomes in complex cardiac operations are often correlated with institutional and surgeon experience.
Overall, PEARS represents an important development in the management of aortic root disease, offering selected patients a personalised approach that preserves their own aorta and aortic valve while avoiding some of the disadvantages associated with conventional aortic root replacement.
Crucially, careful patient selection is fundamental to achieving the best outcomes with PEARS. Not every patient with aortic root dilatation will be suitable for this approach, and the decision should be based on the underlying condition, aortic anatomy, valve function and individual clinical circumstances. Assessment by an experienced surgeon and multidisciplinary aortic team is therefore essential to determine whether PEARS or an alternative surgical strategy is most appropriate.
References
- ExoVasc® Personalised External Aortic Root Support (PEARS) Project Update. Exstent Ltd, May 2019. Available from: https://www.cardion.cz/file/1302/pears-project-update-may-20-2019.pdf
- National Institute for Health and Care Excellence (NICE). Summary of key evidence on PEARS using mesh to prevent aortic root expansion and aortic dissection in people with Marfan syndrome. IPG724 consultation, 2021. Available from: https://www.nice.org.uk/consultations/1542/7/summary-of-key-evidence-on-pears-using-mesh-to-prevent-aortic-root-expansion-and-aortic-dissection
- Pepper J, et al. Personalized external aortic root support (PEARS): A narrative review. Journal of Thoracic and Cardiovascular Surgery, 2024.
- Kougioumtzoglou AM, et al. Personalized external aortic root support: The Dutch experience. PubMed, 2025. PMID: 40769294.
- Redondo A. Personalised External Aortic Root Support (PEARS): Our Preliminary Single Surgeon Results on 100 Patients. AATS Online Institute, American Association for Thoracic Surgery, May 2022.
- Kenny LA, et al. Personalized External Aortic Root Support (PEARS) for aortic root aneurysms. Ochsner Clinical Journal, 2021.
- Marfan Foundation. Personalized External Root (PEARS) Procedure: What You Need to Know. March 2025. Available from: https://marfan.org/wp-content/uploads/2025/03/PEARS-Procedure-What-You-Need-To-Know.pdf
- Treasure T, et al. Personalised external aortic root support (PEARS) in Marfan syndrome: analysis of 1–9 year outcomes by intention-to-treat in a cohort of the first 30 consecutive patients. Heart, 2014;100(12):969-974.
- Metro North Health. Ground-breaking PEARS procedure saves teen's life. Queensland Health, 2024. Available from: https://metronorth.health.qld.gov.au/news/pears-procedure-saves-teens-life
- Top Doctors. Marfan syndrome: What are the symptoms? Available from: https://www.topdoctors.co.uk/medical-articles/marfan-syndrome-do-you-know-the-symptoms-to-look-out-for-in-your-child
