**11. Conclusion**

*Cardiac Surgery Procedures*

the procedure [30].

**8. Sutureless MIAVR**

vular leak (1.8%), a frequent complication of TAVI.

controlled trials are required to confirm this.

**9. Concerns regarding MIAVR**

notomy, there are still areas of concern:

cantly reduced these times.

fewer post-operative complications.

and neurological complications [35].

do valve replacement procedures using trocars.

prosthetic valve.

**10. The future**

ventricle, aortotomy site or right internal mammary, or an inability to defibrillate. A ministernotomy incision can be extended to full sternotomy. With right mini-thoracotomy, incision can be extended to a transverse sternotomy or, alternatively, full sternotomy can be created. It leads to longer bypass times, adding to the morbidity of

Encouraging results have been reported with the three different suture less or rapid deployment bio prosthesis [31, 32]. Micelli et al. [33] reported 38 and 40% decrease in cross clamp and CPB time in RAMT group and 43 and 35% decrease in MS group. The operative mortality was 0.7% with a very low incidence of paraval-

Santarpino et al. [34] reported similar improved results with suture less valves,

suggesting that suture less MIAVR may become the first line treatment in high risk patients in the spectrum between TAVI and conventional AVR. Randomized

Although MIAVR has shown consistently good results compared to full ster-

a.MIAVR is associated with longer cross clamp and CPB times, which are known to have adverse impact upon the results. These times assume greater significance in elderly and high-risk patients. However, the use of suture less valves has signifi-

b.MIAVR is not very "surgeon friendly" due to being a complex and technically challenging procedure. It has a longer learning curve due to the deeper operative field and limited working space for exposure and implantation of the

c.MIAVR has been criticized for the high cost associated with the setting up of a unit of minimally invasive surgery. But these costs are more likely to be compensated by shorter ICU and hospital stays, less blood transfusion requirements and

d.There is also known morbidity associated with peripheral cannulation. It may be associated with a wound infection, pseudo aneurysm formation, limb ischemia

Developments in minimally invasive techniques could potentially lead to totally endoscopic aortic valve replacement (TEAVR) as standard of care for aortic valve replacement [36]. It aims to avoid any sternal fracture or costal spreading by decreasing iatrogenic chest wall trauma. It also aims to maintain advantages of a surgical approach over TAVI. Suture less bio prosthesis technologies are essential to

**64**

MIAVR using RAMT or MS is a safe and effective procedure with excellent post-operative outcomes. Although cross clamp and CPB times may be longer than conventional AVR, use of suture less valve may increase the permeation of MIAVR in the cardiac surgery community. MIAVR with suture less bio prosthesis may be a real alternative to TAVI for the high risk operable patient.
