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Valve-sparing aortic root replacement in patients with Marfan syndrome avoids the complications of a prosthetic heart valve, particularly life-long anticoagulation therapy. Despite proven durability and excellent event-free survival, the majority of cardiac surgeons have not adopted this approach. Here, Stephen Westaby suggests that the time is right for a change in the surgical guidelines and explains that an early, elective valve-sparing operation can transform the long-term prognosis of patients with Marfan syndrome.