Aortic root pathology is a common cause of aortic insufficiency. Aortic root aneurysm and aortic dissection, if left untreated, carry significant risk of mortality and morbidity. Surgical treatment involves replacement of the aortic valve, sinuses and ascending aorta. A number of prosthetic options have been developed including composite valve-synthetic graft, xenograft, homograft and pulmonary autograft. The current review describes the two main indications for aortic root replacement surgery, aortic dissection and root aneurysm, and discusses the various operative strategies and outcomes.