Minimally invasive aortic valve replacement with sutureless valve is the appropriate treatment option for high-risk patients and the "real alternative" to transcatheter aortic valve implantation.

Aortic valve replacement through a full sternotomy is the conventional approach for the treatment of aortic valve stenosis, and clinical outcomes have significantly improved in the last decade, despite gradual increases in patient age and overall risk profile. Nevertheless, new alternative treatment options have been introduced into the clinical practice with the aim of reducing the ‘‘invasiveness’’ of the surgical procedure while maintaining the same quality and safety as a conventional approach. Currently, there are controversies regarding the definition of minimally invasive aortic valve replacement (MIAVR). The Society of Thoracic Surgeons database defines as minimally invasive any procedure not performed with a full sternotomy and cardiopulmonary bypass support and specifically refers to the transcatheter aortic valve implantation (TAVI). Conversely, a scientific statement of the American Heart Association defines minimally invasive cardiac surgery as a procedure done with a small chest incision that does not include the conventional full sternotomy, distinguishing between the percutaneous and surgical approaches. We prefer the latter definition, because it highlights the concept that MIAVR is an operation-specific strategy aiming at reducing the surgical invasiveness. The most common MIAVR approach is the ministernotomy, followed by the right anterior minithoracotomy. Compared with conventional surgery, MIAVR has shown excellent outcomes in terms of mortality, morbidities, and patient satisfaction while providing faster recovery, shorter hospital stay, and better cosmetic results. Several metaanalyses have shown that MIAVR has the advantage of reducing bleeding and blood transfusions, atrial fibrillation, wound infection, and ventilation times, and it improves the respiratory function and reduces the time to return to normal activities. As consequence, MIAVR is associated with fewer rehabilitation resources and reduces costs. These benefits seem to be more evident in patients undergoing right anterior minithoracotomy. Despite these results, MIAVR is performed in a minority of heart centers, and traditionalists claim that it is not ‘‘surgeon friendly’’ because it is technically more complex and requires a long learning curve. The reduction in working space for the exposure and implantation of a sutured valve is more challenging and reflects longer operative times associated with this procedure. Prolonged cardiopulmonary bypass and crossclamp times are associated with adverse outcomes, raising some concerns regarding MIAVR’s safety in elderly and high-risk patients. In this setting, the drawback of increasing operative times could be avoided by the adoption of sutureless technology, which facilitates the MIAVR approach. In recent years, 3 different sutureless and rapiddeployment aortic valves have been introduced in Europe as alternatives to conventional biologic sutured valves for the treatment of mediumto high-risk patients undergoing aortic valve replacement. The Perceval S valve (Sorin Biomedica Cardio srl, Salluggia, Italy), Enable valve (Medtronic, Inc, Minneapolis, Minn), and Edwards Intuity valve system (Edwards Lifesciences, Irvine, Calif) have been designed to avoid passing the stitches through the annulus and suture knotting to simplify the surgical procedure and minimize the ischemic time. All these sutureless valves have shown excellent clinical and hemodynamic outcomes, no structural valve deterioration, and high freedom From the Centro Cardiotoracico, Istituto Clinico Sant’Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy. Disclosers: M.G. has financial interest in Sorin. The other author has nothing to disclose with regard to commercial support. Received for publication Oct 7, 2015; accepted for publication Oct 8, 2015; available ahead of print Nov 19, 2015. Address for reprints: Antonio Miceli, MD, PhD, Centro Cardiotoracico Istituto, Clinico Sant’Ambrogio, Gruppo Ospedaliero San Donato, Via Faravelli 16 20149, Milan, Italy (E-mail: [email protected]). J Thorac Cardiovasc Surg 2016;151:610-3 0022-5223/$36.00 Copyright ! 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.10.028 Mattia Glauber, MD, and Antonio Miceli, MD, PhD