Ministernotomy (MS) is an alternative for total sternotomy (TS) in aortic valve replacement. We compared these two approaches for results and adverse effects in a prospective study. From January to December 2000, 100 patients who underwent aortic valve replacement were included in two groups of 50 according to the surgical approach that used MS or TS; one senior surgeon performed all cases in each group. Valvular pathologies were either stenosis or insufficiency. Mean age was 63 +/- 14 years in MS, 67 +/- 12 in TS (p = ns). NYHA class was 2.7 +/- 0.5 in MS, 2.8 +/- 0.6 in TS (p = ns). Left ventricular ejection fraction was 58 +/- 12% in MS, 57 +/- 12% in TS (p = ns). There was a significant difference between MS and TS in aortic cross-clamping (66 +/- 14 min vs 48 +/- 9 min) and cardiopulmonary bypass (88 +/- 18 min vs 69 +/- 10 min, p < 0.01), but not in intervention times (2.8 +/- 0.4 hours vs 2.7 +/- 0.4 hours). Mean intensive care stay was reduced in MS (1.7 +/- 1.6 days vs 2.6 +/- 6 days, p < 0.05). Intubation times (12 +/- 7 hours vs 14 +/- 9 hours), 24 hours bleeding (394 +/- 219 mL vs 465 +/- 318), reintervention for hemostasis (4% vs 2%), rhythmic complications (14% vs 14%), and mortality at 1 month (2% vs 2%) were comparable in MS and TS. In aortic valve surgery, ministernotomy is technically more demanding and needs more time. It is as safe and as effective as conventional sternotomy but its eventual benefits, excepting upon cosmesis, are still to be defined.