ORIGINAL ARTICLE Sutureless Aortic Valve Replacement via Partial Sternotomy Sven Martens, MD, Andreas Zierer, MD, Anja Ploss, MD, Sami Sirat, MD, Aleksandra Miskovic, MD, Anton Moritz, MD, and Mirko Doss, MD Objective: For elderly patients with symptomatic aortic valve ste- nosis, aortic valve replacement with tissue valves is still the treat- ment of choice. Stentless valves were introduced to clinical practice for better hemodynamic features as compared with stented tissue valves. However, the implantation is more complex and time de- manding, especially in minimal invasive aortic valve replacement. We present our clinical data on 22 patients having received a sutureless ATS 3f Enable aortic bioprosthesis via partial upper sternotomy. Methods: The procedure was performed using CPB with cardiople- gic arrest. After resection of the stenotic aortic valve and debride- ment of the annulus, the valve was inserted and released. Mean age was 79 years, and mean logistic Euroscore was 13. Subvalvular myectomy was performed in two patients. Prosthetic valve sizes were 19 mm (n = 1), 21 mm (n = 7), 23 mm (n = 6), 25 mm (n = 6), and 27 mm (n = 2). Results: Implantation of the valve required 10  6 minutes. Car- diopulmonary bypass and aortic crossclamp time were 87  16 and 55  11 minutes, respectively. Early mortality (90 days) was 9% (2 patients). No paravalvular leakage was detected intraoperatively or in follow-up echocardiography. The mean transvalvular gradients were 9  6 mm Hg at discharge and 8  2 mm Hg at 1-year follow-up. Conclusions: Sutureless valve implantation via partial sternotomy is feasible and safe with the ATS 3f Enable bioprosthesis. Reduction of cardiopulmonary bypass and aortic crossclamp time seems possible with increasing experience. Hemodynamic data are very promising with low gradients at discharge and after 12 month. Sutureless valve implantation via minimal invasive access may be an alternative treatment option for elderly patients with high comorbidity. Key Words: Aortic valve replacement, Bioprosthesis, Minimal invasive. (Innovations 2010;5:12–15) E xposure of the aortic valve using complete median ster- notomy is still the standard approach for aortic valve replacement (AVR) in most institutions, but at the cost of complete interruption of the bone chest. Partial upper ster- notomy as a minimal invasive approach for valve procedures was already suggested by Cohn et al 1 in 1990s. The sternot- omy was performed with an oscillating saw down to the third intercostals space (right side of the sternum). A series of eight patients undergoing aortic root surgery for Marfan syndrome was published by Sun et al 2 ; they combined superior minis- ternotomy with placement of the cannulas in the femoral artery and vein, respectively. A larger cohort of patients undergoing AVR via partial upper sternotomy was presented by Masiello et al 3 in 2002, and they found surgical results to be similar as compared with standard median sternotomy, but operating times were significantly longer, a finding that was supported by the study of Corbi et al 4 in 2003. In the same year, Candaele et al 5 stated that partial upper sternotomy improves pulmonary function and reduces pain as compared with standard full sternotomy for AVR. In the same year, our group reported results of a prospective randomized trial, comparing partial upper sternotomy down to the fourth intercostals space (left side of the sternum) with standard median sternotomy. We found significantly less blood loss with slightly prolonged operative times in the group undergoing minimal invasive AVR. 6 Early and late outcomes of 1000 minimally invasive aortic valve operations performed via partial upper sternotomy were pub- lished in 2008 by Tabata et al. 7 The interest of minimally invasive valve procedures is primarily driven by the anticipated benefit for the patient, including achievement of the same quality of treatment with reduced operative mortality and morbidity. However, espe- cially in elderly patients with important comorbidity, the issue of increased cardiopulmonary bypass (CPB) and cross- clamp time reported with partial sternotomy has to be taken into account. Thus, sutureless bioprosthetic valves, allowing for faster implantation, should contribute to a reduction of the surgical trauma in aortic valve patients. The ATS 3f Enable (ATS Medical, Minneapolis, MN; Fig. 1) is a modification of the ATS 3f stentless aortic valve prosthesis, which consists of a tubular structure assembled from three equal sections of equine pericardial tissue. 8 Our group presented clinical and Accepted for publication October 11, 2009. From the Department of Thoracic and Cardiovascular Surgery, JWGoethe University Hospital, Frankfurt am Main, Germany. Supported by ATS Medical, Inc, research grant. Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, San Francisco, CA USA, June 3– 6, 2009. Disclosure: Sven Martens, MD, is a consultant for ATS Medical, Minne- apolis, MN USA. Address correspondence and reprint requests to Sven Martens, MD, Depart- ment of Thoracic and Cardiovascular Surgery, JWGoethe University Hospital, Theodor Stern Kai 7, D-6 0590 Frankfurt, Germany. E-mail: martens.herz@gmx.de. Copyright © 2010 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/10/0501-0012 Innovations • Volume 5, Number 1, January/February 2010 12