OBJECTIVE Aortic valve replacement (AVR) in patients with a heavily calcified ascending aorta and aortic root, or with conditions that preclude a median sternotomy, poses a formidable challenge. A left ventricle apical-aortic conduit (AAC) is an alternative in these situations. Herein, the authors' experience with AAC in adult patients with acquired aortic stenosis is reported. METHODS Between 1995 and 2003, 13 patients (mean age 71 years) underwent AAC for severe symptomatic aortic stenosis (mean valve area 0.65 +/- 0.02 cm2). Indications for AAC were heavily calcified ascending aorta and aortic root (n = 5), patent retrosternal mammary grafts (n = 4), calcified ascending aorta and aortic root plus patent retrosternal mammary graft (n = 1), retrosternal colonic interposition (n = 1) and multiple previous sternotomies (n = 2). Seven patients had previous coronary artery bypass grafting (CABG). The mean preoperative left ventricular ejection fraction was 50 +/- 4%. RESULTS AAC were performed under cardiopulmonary bypass through a left thoracotomy (n = 10), median sternotomy (n = 2) or bilateral thoracotomy (n = 1). Hearts were kept beating (n = 5) or fibrillated (n = 7). Circulatory arrest was used in one patient. Composite Dacron conduits with biological (n = 6), mechanical (n = 4) or homograft (n = 2) valves were used. Distal anastomoses were performed in the descending thoracic aorta (n = 12) or in the left iliac artery (n = 1). Two patients underwent simultaneous CABG. Three patients died in-hospital from ventricular failure (n = 1), intravascular thrombosis (n = 1) and multi-organ failure (n = 1). The mean hospital stay was 26 days. Complications included respiratory failure requiring tracheostomy (n = 2), stroke (n = 1) and re-exploration for bleeding (n = 2). At a mean follow up of 2.1 years, there have been four late deaths; causes of death were congestive heart failure (n = 2), ischemic cardiomyopathy (n = 1) and cancer (n = 1). CONCLUSIONS AAC provides an acceptable alternative to AVR in selected patients who are at exceedingly high risk for the standard procedure.