Scarless aortic valve replacement (periareolar approach) with a limited suture technique

Periareolar incision for endoscopic aortic valve replacement via the 9-suture technique Femoral Vessel Exposure Incision above the groin crease reduces complications. Partial vessel exposure (no full isolation) with purse-string sutures (4/0 Prolene for vein, pledgeted 5/0 Gore-Tex for artery). Surgical Access Periareolar incision (third intercostal space): muscle-sparing, hidden scar, Alexis retractor for exposure. Left ventricular vent (fifth intercostal space): CO₂ insufflation (2 L/min) to prevent air embolism. Camera port (third intercostal space: for visualization and retraction). Femoral Cannulation Seldinger's technique under transoesophageal echocardiography guidance; venous cannula to the superior vena cava (vacuum-assisted), artery. Pericardiotomy and Clamp Placement Incision anterior to phrenic nerve; stay sutures for exposure. Chitwood clamp inserted via second intercostal space to stabilize the aorta. Cardioplegia and Aortotomy Antegrade Custodiol cardioplegia via 3-0 Prolene purse-string suture. Horizontal aortotomy after cross-clamping. Valve Excision and Suture Placement (9-Suture Technique) Valve excised; annulus decalcified. Pledgeted horizontal mattress sutures (3 commissural, 2 per cusp) placed strategically. Valve Implant and Closure Sutures passed through the prosthetic valve, parachuted, secured with Cor-Knot. Aortotomy closed in two layers (pledgeted mattress + running suture). De-airing and Weaning Trendelenburg, left ventricle vent suction, isolated lung ventilation. Pacing wires placed; pericardium closed. Chest Drain and Closure Drains inserted; femoral cannulae removed post-heparin reversal. Periareolar incision closed with muscle suture for cosmesis. Outcome No paravalvular leak, early extubation (2 h), discharge by postoperative day 4. Cosmetic advantage, less pain, faster recovery versus sternotomy. Reduced suture count lowers left ventricular outflow tract gradients without increasing leak risk. Conclusion This minimally invasive approach improves outcomes and patient satisfaction, supported by optimized anticoagulation (international normalized ratio 1.5-2.0) for newer version of mechanical valves.