**1. Introduction**

Conventional full median sternotomy aortic valve replacement (AVR) has remained the standard approach to AVR for many years. In-hospital mortality of 2.3% for isolated conventional AVR (22,107 patients) has been reported in German Aortic Valve Registry [1]. Despite these excellent results, full sternotomy incision has been criticized for its length, postoperative pain and possible complications including sternal wound dehiscence, which dramatically increase the morbidity of the procedure [2].

The introduction of minimally invasive aortic valve surgery began in the last decade of twentieth century. The first minimally invasive AVR was performed by Cosgrove and Sabik in 1996 using a parasternal approach [3]. Bennetti et al. used the right thoracotomy approach in 1997 [4]. In 1998, Gundry et al. [5] reported a partial upper mini sternotomy approach in both adult valve and congenital procedures. Minimally invasive aortic valve surgery has recently moved from simple modifications of conventional steps to totally endoscopic aortic valve replacement (TEAVR) [6].

Although results of many retrospective and prospective studies behold a bright future for this approach, the prevalence of minimally invasive aortic valve replacement (MIAVR) has not met potential expectations: 29% of AVRs are done minimally invasive in Germany [7] and 12% in the UK [8]. Kaneko et al. [9] reported that 12% patients had hemi sternotomy AVR and 3.6% patients were operated via an anterior mini-thoracotomy approach in the USA.

A possibly long learning curve and complexity of the procedure may dissuade the widespread uptake of MIAVR. In an era of trans-catheter aortic valve implantation (TAVI) [10], sufficient motivation should be present for cardiac surgeons to adopt MIAVR in majority of patients, especially considering the recent promising results [11].
