• Changes in the self-efficacy domain of the Kansas City Cardiomyopathy Questionnaire (KCCQ) [ Time Frame: One, three, six and twelve months after surgery ]
  Changes in the self-efficacy domain of the KCCQ, after aortic valve replacement.
• Changes in social interference domain of the Kansas City Cardiomyopathy Questionnaire (KCCQ) [ Time Frame: One, three, six and twelve months after surgery ]
  Changes in social interference domain of the KCCQ, after aortic valve replacement.
• Changes in quality of life domains of the Kansas City Cardiomyopathy Questionnaire (KCCQ) [ Time Frame: One, three, six and twelve months after surgery ]
  Changes in quality of life domain of the KCCQ, after aortic valve replacement.
• Change is generic quality of life, assessed with the Physical Component Summary (PCS) of the Short Form-36 (SF-36). [ Time Frame: One, three, six and twelve months after surgery ]
  The SF-36 consists of eight domains: physical functioning, role physical functioning, role emotional functioning, bodily pain, vitality, mental health, role social functioning and general health. These domains can be combined into the PCS and MCS.
• Change is generic quality of life, assessed with the Mental Component Summary (MCS) of the Short Form-36 (SF-36). [ Time Frame: One, three, six and twelve months after surgery ]
  The SF-36 consists of eight domains: physical functioning, role physical functioning, role emotional functioning, bodily pain, vitality, mental health, role social functioning and general health. These domains can be combined into the PCS and MCS.
• Postoperative sternal pain [ Time Frame: First seven days after surgery and one, three, six and twelve months after surgery ]
  Assessed with a visual analogue score. The VAS is depicted as a straight line from left to right and ranges from 0 (no pain) to 100 (worst imaginable pain)
• Perioperative outcomes [ Time Frame: During surgery ]
  aortic cross clamp time (minutes), cardio-pulmonary bypass time (minutes), operating time (minutes) are the main focus. All three outcomes will be measured in minutes.
• Clinical outcomes [ Time Frame: Up to one year postoperatively. ]
  30-day mortality and one year mortality rate, complication rate, reoperation rate and readmission rate
• Technicall success rate of the aortic valve replacement. [ Time Frame: During surgery (peri-operatively) ]
  Technical success rate is defined as a limited access approach without conversion and placement of the rapid deployment bioprosthesis
• Hospital length of stay [ Time Frame: Up to one year postoperatively ]
  The number of days a patient is admitted in the hospital after surgery (aortic valve replacement)
• Intensive Care length of stay [ Time Frame: Up to one year postoperatively ]
  The hours a patient has to stay in the Intensive Care Unit postoperatively
• Effective orifice area of the aortic valve prosthesis [ Time Frame: Up to one year postoperatively ]
  Postoperatively hemodynamic outcomes of the aortic valve prosthesis that is placed during surgery will be measured. A transthoracic echocardiography will be made during follow-up. The effective orifice area, in square centimeters (cm^2), will be measured.
• Need of analgetic drugs [ Time Frame: Up to one year postoperatively ]
  The intake of analgesic drugs (paracetamol and morfine) will be measured.
• Mean pressure gradient of the aortic valve prosthesis. [ Time Frame: Up to one year postoperatively ]
  Postoperatively hemodynamic outcomes of the aortic valve prosthesis that is placed during surgery will be measured. A transthoracic echocardiography will be made during follow-up. The mean pressure gradients in milimeters of mercury (mmHg) will be measured.

The LIAR-Trial is a single-center, single blind randomized controlled clinical trial comparing patients undergoing isolated AVR via J-shaped upper hemi-sternotomy (UHS) and conventional AVR through a full median sternotomy (FMS). To reduce potential confounding by differences in implanted valve prostheses, in both arms of the trail, the diseased native aortic valve is planned to be replaced with a rapid deployment stented aortic bioprosthesis (Edwards Intuity Elite Valve System®, Edwards Lifesciences Corporation), the preferred type of valve prosthesis for a limited access approach. Patients will be randomized 1:1 to both arms with 80 patients per arm. Patients who are unwilling or unable to participate in the randomized study will be treated via conventional median sternotomy with a sutured aortic valve prosthesis and participate in a prospective registry.

Primary outcome is cardiac-specific quality of life, measured by two domains of the Kansas City Cardiomyopathy Questionnaire (KCCQ), up to one year after surgery. Secondary outcomes include, but are not limited to: generic quality of life measured with the Short Form-36 (SF-36), postoperative pain, perioperative outcome (i.e. technical success rate, operating time) and postoperative outcome (i.e. 30 day and one-year mortality, complication rate, hospital length of stay, reoperation rate and readmission rate). Questionnaires are administered face to face or by telephone prior to surgery and at one, three, six and twelve months after surgery. In the prospective registry the quality of life questionnaires and all clinical data from the patients will be collected and analyzed the exact same way as the data from patients included and randomized in the trial.

• Aortic Valve Stenosis
• Limited Access Aortic Valve Replacement
• Quality of Life

• Procedure: Limited access aortic valve replacement.
  Limited access aortic valve replacement through partial upper hemisternotomy
• Procedure: Conventional aortic valve replacement
  Aortic valve replacement through full median sternotomy

• Active Comparator: Conventional group
  All patients undergoing aortic valve replacement through full sternotomy.
  Intervention: Procedure: Conventional aortic valve replacement
• Experimental: Limited access group
  All patients undergoing aortic valve replacement through partial upper hemisternotomy.
  Intervention: Procedure: Limited access aortic valve replacement.
• Registry group

  All patients unwilling or unable to participate in the randomized part of the trial.

  All patients will undergo aortic valve replacement through median full sternotomy.

  Intervention: Procedure: Conventional aortic valve replacement

Inclusion Criteria:

• Patients undergoing an isolated biological aortic valve replacement for a severe and/or symptomatic aortic valve stenosis, defined as:

  • An aortic valve area of ≤1.0cm2, and;
  • Mean valve gradient ≥40mmHg, and/or;
  • A peak velocity of at least 4.0m/s.
• Able to understand the nature of the study and what will be required of them;
• All adult men and non-pregnant women;
• BMI between 18-35.

Exclusion Criteria:

• Inability to give written informed consent;
• Inability to adequately answer the questionnaires;
• Patients requiring additional cardiac surgery during the same procedure;
• Patients requiring a reoperation;
• (relative) contraindications for a limited access approach;
• Undergoing an emergency operation;
• Recent myocardial infarction (<90 days);
• Recent stroke or transient ischemic attack (<6 months);