Background: The aim of this study was to assess the efficacy and applicability of on-pump beating heart aortic valve replacement with retrograde coronary sinus (CS) warm blood perfusion. Methods: The prospective study included 14 consecutive patients who underwent aortic valve replacement with mechanical prosthesis using retrograde CS perfusion. The operative variables and early outcome of this procedure are presented. Results: Retrograde CS perfusion and venting the heart from the pulmonary vein provided good visualization of the operative field and performance of the operations without any difficulty. Partial oxygen pressures of CS perfusion blood and the returning blood from the coronary ostia were 288.5 +/- 34.4 and 39.6 +/- 4.6 mmHg, respectively. Postoperative peak creatine kinase-MB and troponin T values were mean 77.0 +/- 63.6 IU/L and mean 0.8 +/- 0.7 ng/mL, respectively. No mortality or major complication was observed and all the patients were discharged from the hospital in good condition. Conclusions: On-pump beating heart aortic valve replacement with retrograde CS warm blood perfusion is a good surgical option, and has the advantage of maintaining physiologic condition of the heart throughout the procedure.