OBJECTIVES:  Sutureless prosthesis for aortic valve replacement (AVR) enriches the armamentarium of cardiac surgeons. Usefulness of this device in various settings has been reported, but data from randomized studies comparing traditionally sutured and sutureless valves are lacking. Consequently, what type of patients benefits most is unclear and the economic burden of this new technology in the real world is unknown. METHODS:  At our Institution, a private non-profit hospital collaborating with the National Health Service, we reserved sutureless prostheses, which are more expensive than sutured ones, for patients deemed at high surgical risk. In this way, two groups of patients were available for a retrospective analysis of outcome and resource consumption from the hospital’s point of view (1/2013-6/2015). To favor the comparison, only patients with the main characteristics required by the Instructions-For-Use of the sutureless device were reviewed. RESULTS:  The sutureless group (SU-AVR,113 pts) had a higher risk profile than the sutured one (ST-AVR,121 pts) expressed by higher hospital mortality prediction, according to EuroSCORE (SU-AVR 3.9%,IQR 2.2-7.1; ST-AVR 2.3%,IQR 1.4-3.6;p<0.001) and to Society-of-Thoracic-Surgeons Score (SU-AVR 3.55%,IQR 2.02-5.75; ST-AVR 2.21%,1.59-3.21;p<0.001). SU-AVR had shorter cardiopulmonary-bypass and cross-clamp times (for isolated AVR, SU-AVR 79.4±20.3min. and 52.9±12.6min; ST-AVR 92.9±18.1min and 69±15.2min;p<0.001 for both). Hospital outcome: mortality 0.9% in SU-AVR and nil in ST-AVR,p=0.483; intubation time 7 hours (IQR 5-10.7) vs. 7 (IQR 5-9),p=0.795; ICU stay 1 day (IQR 1-1) vs. 1 (IQR 1-1),p=0.57; ward stay 5.5 days (IQR 4-7) vs. 5 (IQR 4-6),p=0.002. Overall hospital cost (excluding the prosthesis) was euro 12,017 (IQR 11,009-14,368) for SU-AVR and 11,684 (IQR 10,528-13,450) for ST-AVR,p=0.097. CONCLUSIONS:  Despite an increased clinical risk in the sutureless group, hospital mortality did not differ. Operative times were lower in SU-AVR and this improvement may have impacted favorably many postoperative endpoints. A worse economic impact was expected according to the profile of SU-AVR patients, but resource consumption did not differ.