The advent of minimally invasive sutureless and rapid deployment aortic valve replacement (MI-SURD-AVR) was made possible by the synergy of many techniques—and technologies as well—that together contributed to achieve the most significant evolution of the original technique first described by Harken in 1962 ( ). However, even more important are the reasons that motivated these technical advancements—fostering the spirit of innovation typical of the founding fathers of cardiac surgery—including (I) lengthening of life expectancy, resulting in higher fragility and comorbidity burden, (II) changes in the etiology of aortic valve disease, with the transition from rheumatic to calcific degeneration, and (III) the need for improving patient compliance ( ). These key features mark the differences in AVR between the past and the present century, and promoted the development of MI-SURD-AVR. In order to address these needs, both minimally invasive accesses (mini-J sternotomy and right anterior mini-thoracotomy) have been conceived, and new prostheses have also been developed. These two major advances in the field of cardiac surgery were applied to the same category of patients, and strengthened their effectiveness mutually. The minimally invasive approach is associated with high levels of patient satisfaction, because patients not only benefit from a limited skin incision, but also experience lower postoperative pain, fewer blood product transfusions, reduced postoperative ventilation time, faster mobilization, and reduced stay in an intensive care unit ( ). Despite the slow pace of acceptance of MI-AVR within the cardiac surgery community, signs of change are being observed. A report by the German cardiac surgery society recorded 34.1% patients undergoing AVR performed by partial sternotomy in 2018 ( ), as compared to 19.7% in 2013 ( ). Without underestimating the role of the advent of transcatheter aortic valve implantation (TAVI), the cause of this shift is also to be found in the growing volume of scientific evidence. After the first small and underpowered studies, the minimally invasive approach has increasingly shown better outcomes than traditional surgery in larger multicenter studies ( ). Nevertheless, a randomized trial is still lacking.
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