Port-access Mitral Valve Research Articles

State-of-the-Art Review: Technical and Imaging Considerations in Novel Transapical and Port-Access Mitral Valve Chordal Repair for Degenerative Mitral Regurgitation.

Degenerative mitral regurgitation (DMR) based on posterior leaflet prolapse is the most frequent type of organic mitral valve disease and has proven to be durably repairable in most cases by chordal repair techniques either by conventional median sternotomy or by less invasive approaches both utilizing extracorporeal circulation and cardioplegic myocardial arrest. Recently, several novel transapical chordal repair techniques specifically targeting the posterior leaflet have been developed as a far less invasive and beating heart (off-pump) alternative to port-access mitral repair. In order to perform a safe and effective minimally invasive mitral chordal repair, thorough knowledge of the anatomy of the mitral valve apparatus and adequate use of multimodality imaging both pre- and intraoperatively are fundamental. In addition, comprehensive understanding of the available novel devices, their delivery systems and the individual procedural steps are required.

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Cost analysis of minimally invasive compared to conventional mitral valve surgery

Objective Minimally invasive cardiac surgery through port-access has been advocated as a valid alternative for conventional full sternotomy approaches. However, the full economic consequences are unclear. We undertook an analysis of our own data to address these uncertainties.Methods Retrospective data, on patients who underwent single mitral valve surgery (repair or replacement) were included in our analysis. These were allocated into two cohorts based upon the intended surgical approach: either port-access or full sternotomy. Propensity score matching was performed to avoid confounding factors. Comprehensive clinical and cost data, based on hospital charges and a cost allocation model, were collected.Results There were fewer complications with port-access versus full sternotomy. Operation times were longer but there was a shorter intensive care and total hospital stay. Port-access resulted in comparable overall costs (€ 21,041 ± 3,743 compared with € 23,999 ± 15,007 for full sternotomy; mean and standard deviation). A breakdown into accounting groups showed reductions in several costs categories (i.e. nursing costs, technical fees, and pharmacy drugs/implants) except for materials. Patient costs were higher for the port-access group due to higher material costs (€ 1,917 ± 602 versus € 1,145 ± 659; mean and standard deviation). From a hospital perspective direct costs were comparable in both cohorts.Conclusion Port-access mitral valve surgery in UZ Leuven has at least comparable short-term clinical results as full sternotomy. It is associated with comparable costs for the acute-treatment phase for the health insurance system and the hospital, but higher patient costs.

Aortic Dissection Type a after Right Atrial Cryoablation during Port Access Mitral Valve Surgery

The case of a 63-year-old woman who underwent minimal invasive mitral and tricuspid valve repair and a concomitant CryoMaze is described. During creation of the last lesion of the right-sided maze procedure, dissection of the ascending aorta occurred that necessitated emergency sternotomy, replacement of the ascending aorta, and aortocoronary bypass grafting to the right coronary artery (RCA) because of detachment of the RCA from the aortic annulus. Repair of this complication was successful; nevertheless, the patient died 5 days after the operation because of multiorgan failure. The cause of this complication can only be speculated, but a relation to the CyroMaze is obvious. Because of the restricted incision with impaired vision especially in the area of the right atrial appendage, the cryoprobe could have come into contact with the orifice of the RCA during the last lesion, with subsequent detachment of the RCA from the aorta, which could subsequently have caused dissection.

Aortic Dissection Type a after Right Atrial Cryoablation during Port Access Mitral Valve Surgery

Aortic Dissection Type a after Right Atrial Cryoablation during Port Access Mitral Valve Surgery

Port-access mitral valve replacement after surgical correction for Bland-White-Garland syndrome

A 79-year-old woman with Bland-White-Garland syndrome was admitted to our institution for surgical treatment of severe mitral regurgitation (MR). She had previously undergone mitral valve repair and coronary artery bypass grafting for both mitral insufficiency and a coronary artery anomaly 14 years earlier. However, the degree of residual MR had gradually worsened, and redo mitral valve surgery was scheduled. Multidetector row computed tomography revealed that the right coronary artery (RCA) was dilated and located just behind the sternum, and saphenous vein graft bypassed to the left anterior descending artery was occluded. This meant that the RCA was the only vessel supplying coronary blood flow. We successfully performed port-access mitral valve replacement under mild hypothermia with fibrillatory arrest to prevent damage to the RCA. We propose that port-access surgery is a safe and effective treatment for redo cardiac surgery after initial surgical correction of a congenital heart anomaly.

EComment: Port-access mitral valve repair in re-do surgery

eComment: Port-access mitral valve repair in re-do surgery

Is a port-access mitral valve repair superior to the sternotomy approach in accelerating postoperative recovery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether port-access mitral valve repair reduces the recovery period of patients compared to the conventional sternotomy approach. Using the reported search, 778 papers were identified. Thirteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The 13 papers demonstrated that patients who undergo minimally invasive mitral valve repair have a shorter ICU and total hospital stay than those who undergo the sternotomy approach. Results vary but mean hospital stays range from 5.6 to 13 days in port-access groups compared to 6.25-15 days in sternotomy groups. Other advantages over the sternotomy approach were reduced postoperative bleeding and pain, shorter time to extubation and a quicker return to daily activities. However, it is consistently reported that operative time is longer, with the increase in bypass time being around 30 min. We conclude that in several cohort studies minimally invasive mitral valve repair is reported to result in a shorter ICU and hospital stay, reduced postoperative bleeding and pain and a shorter time to resuming normal activities. This is at the expense of longer bypass and operative times.

Pectoral Muscle Hematoma After Axillary Artery Catheterization in a Patient Undergoing Minimally Invasive Mitral Valve Surgery

c l t i d f t r c a e a a p v c w w ( HE AXILLARY ARTERY can be cannulated in the operating room in order to provide continuous hemodynamic onitoring during major surgery or in critically ill patients.1 It s cannulated when other vessels, such as the radial, brachial, nd femoral arteries, are unavailable or when several attempts o insert an arterial catheter have failed. Sandhu2 has recently escribed a new anterior approach for axillary artery catheterzation using real-time sonography. The technique reported by Sandhu2 has recently been used in patient undergoing port-access mitral valve replacement. The uthor’s protocol used for this kind of surgery includes bilateral adial artery catheters, aortic root pressure, and transesophageal chocardiography of the ascending aorta to monitor the potenial migration of an endoaortic clamp catheter.3-5 Several unuccessful attempts were made to cannulate the left radial and rachial arteries in this patient. A catheter was then placed in he left axillary artery by passing a 16-G catheter through the ectoral muscles under real-time sonography.

Multifrequency transcranial Doppler for intraoperative automatic detection and characterisation of cerebral microemboli during port-access mitral valve surgery

In 20 patients (6 male; age 56.5+/-6.4 years; BSA 1.6+/-0.1 m(2)) undergoing port-access mitral valve surgery, automated intraoperative transcranial Doppler was used to monitor absolute amount, side distribution, and type of embolic events during selected phases of the procedure to evaluate the impact of specific surgical manoeuvres on cerebral microembolism. The rate of events per minute was acquired for the following five operative periods: from cardiopulmonary bypass (CPB) set-up to CPB start, from CPB start to aortic clamping, first minute after aortic endoclamp inflation, first minute after aortic endoclamp deflation, and first ten minutes from CPB weaning start. Endoclamp navigation into the aortic arch, CPB start and CPB weaning determined the highest absolute count of embolic events. When embolic rate was normalised for length of selected operation periods CPB start (1.58+/-1.9 events/min), endoclamp inflation (1.42+/-1.7 events/min) and endoclamp deflation (3.1+/-3.5 events/min), resulted as the most critical phases. No side prevalence was observed. In conclusion, brain embolism during port-access mitral valve procedures occurs predominantly at CPB start and during ascending aorta clamping and unclamping. Aortic arch navigation with catheters exposes to the risk of cerebral embolic events.

The introduction of endoscopic heart valve surgery into the UK

The introduction of endoscopic heart valve surgery into the UK

Minimally Invasive Port Access Versus Conventional Mitral Valve Surgery: Prospective Randomized Study

We compared the port access mitral valve surgery with the conventional procedure through median sternotomy in a prospective randomized study. Forty elective patients with mitral valve disease were prospectively randomized to undergo minimally invasive (group I) or conventional (group II) mitral valve operation. The patients of group I had limited access through right small anterior thoracotomy and a femorofemoral cardiopulmonary bypass system using the endoclamp technique. To assess the efficiency and safety of the procedure, intraoperative and postoperative clinical data and markers of myocardial, cerebral, and lower limb ischemia were collected. Pulmonary function tests were performed to compare the preservation of pulmonary function. Neuropsychological tests were conducted for quantification of neurological and cognitive disorders. Mitral valve reconstructions were performed in 28 patients (70%) in both groups. Intraoperative procedure-associated problems were experienced in 9 patients (45%) in group I, and 6 of them (30%) had to be converted to direct transthoracic aortic clamping. Markers of myocardial and cerebral damage as well as pulmonary and neuropsychological tests did not show statistically significant difference between groups. The minimally invasive port access technique for mitral valve surgery can be done with similar clinical safety as procedures through median sternotomy. The problems with endoclamping have forced us to change our practice to the more simple and economic transthoracic aortic clamping technique.

INVITED COMMENTARY

Reichenspurner and colleagues have compared two innovative surgical techniques used during 120 video-assisted minimally invasive (MI) mitral valve operations. Either the port-access (Cardiovations, Sommerville, NJ) method using an occluding intraaortic balloon (n = 60) or a simpler transthoracic aortic clamp (Scanlan International, Minneapolis, MN) technique (n = 60) was used. All operations were done through a 6 to 10 cm minithoracotomy with either a two-dimensional or three-dimensional camera, two-thirds of which were guided by AESOP (Intuitive Surgical, Mountain View, CA), a voice-activated robotic-arm assistant. There was no operative mortality and hospital stays were similar for both groups. Repair results were excellent, and met the standards of conventional mitral surgery. Operative, cardiopulmonary bypass, and cardiac arrest times were shorter when using the transthoracic clamp. Moreover, costs were significantly less in clamp patients, who also had fewer operative complications with less bleeding and fewer peripheral vascular problems. In 1998 Mohr and colleagues [1Mohr F.W. Falk V. Diegeler A. et al.Minimally invasive port-access mitral valve surgery.J Thorac Cardiovasc Surg. 1998; 115: 567-571Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar] reported that retrograde arterial passage and balloon aortic occlusion could be fraught with neurological complications and aortic dissections. However, port-access balloon systems have evolved greatly since then, and risks are much less when applied with echocardiographic monitoring. Using aortic balloon occlusion for mitral surgery, Casselman and coworkers [2Casselman F.P. Van Slycke S. Dom H. Lambrechts D.L. Vermeulen Y. Vanermen H. Endoscopic mitral valve repair: Feasible, reproducible, and durable.J Thorac Cardiovasc Surg. 2003; 125: 273-282Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar] has demonstrated safety efficacy and experienced few complications in his large series. With femoral artery inserted balloons, the aorta does not have to be accessed directly to establish antegrade cardioplegia or venting. Despite the elegance and seeming advantages of port-access systems, a significant learning curve exists and balloon monitoring must be continuous to assure adequate myocardial protection and a stable ascending aortic position, proximal to the innominate artery. Our group developed the transthoracic aortic clamp in 1996, and has used it in more than 450 minimally invasive video-assisted mitral valve repairs. The cost of a multiuse clamp in miniscule compared with single-use balloon systems. Moreover, the ease in clamp application maximizes surgeon familiarity and minimizes anxiety. The report of Reichenspurner and colleagues suggests diminished individual operative times when he used the clamp, and his times were similar to ours [3Felger J.E. Chitwood W.R. Nifong L.W. Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach.Ann Thorac Surg. 2001; 72: 1203-1209Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar]. We have experienced no aortic injuries, retrograde aortic dissections, or clamp dislodgements during surgery. However, early our series a right pulmonary artery injury and a left atrial appendage clamp tear occurred. Thus, during application, either direct visual or endoscopic confirmation of clamp position is paramount to avoid injury of these structures in the transverse sinus. This study compares these two methods and describes that minimally invasive, small thoracotomy mitral surgery is safe and can be done by most surgeons. Both methods have advantages and disadvantages. Our mitral operations are done through a 4-cm incision. We have found that with smaller incisions it becomes difficult to provide direct aortic root cardioplegia using the clamp. With true endoscopic robotic surgery, port-access balloons may provide the best avenue for cardiac arrest. Also, reoperations limit access to the aorta, and balloon occlusion seems preferable to avoid tissue dissection. Nevertheless, most surgeons can apply the clamp technique effectively. Despite the advantages of the transthoracic clamp, both methods can provide an effective less invasive approach for mitral valve surgery, and both can widening each surgeon's operative armamentarium.

Robotic cardiac surgery: Present and future applications

THE TREND IN cardiac surgery is to minimize patient trauma while reducing the incidence of perioperative morbidity and mortality. Minimally invasive techniques have been introduced to fulfill such expectations. In coronary artery surgery, the use of smaller surgical incisions and avoidance of cardiopulmonary bypass (CPB) are becoming standard practices. 1 Calafiore AM Di Giammarco G Teodori G et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996; 61: 1658-1665 Abstract Full Text PDF PubMed Scopus (563) Google Scholar , 2 Buffolo E de Andrade JCS Branco JNR et al. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 1996; 61: 63-66 Abstract Full Text PDF PubMed Scopus (553) Google Scholar , 3 Benetti FJ Naselli G Wood M Geffner L Direct myocardial revascularization without extracorporeal circulation: Experience in 700 patients. Chest. 1991; 100: 312-316 Crossref PubMed Scopus (541) Google Scholar Advancements in surgical instrumentation have increased interest in endoscopic cardiac surgery. 4 Chitwood WR Editorial: Endoscopic robotic coronary surgery—is this fact or fantasy?. J Thorac Cardiovasc Surg. 1999; 118: 1-3 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar , 5 Mack M Acuff T Yong P et al. Minimally invasive thoracoscopically assisted coronary artery bypass surgery. Eur J Cardiothorac Surg. 1997; 12: 20-24 Crossref PubMed Scopus (37) Google Scholar , 6 Mohr FW Falk V Diegeler A et al. Minimally invasive Port-Access mitral valve surgery. J Thorac Cardiovasc Surg. 1998; 115: 567-576 Abstract Full Text Full Text PDF PubMed Scopus (347) Google Scholar Despite some difficulties that must still be overcome, the development of precise and intelligent robotic-enhanced instruments has reached the point where it has become possible to do cardiac surgical procedures through ports that cause minimal injury. 7 Carpentier A Loulmet D Aupecle B et al. Computer-assisted cardiac surgery. Lancet. 1999; 353: 379-380 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar , 8 Mohr FW Falk V Diegeler A Autschbach R Computer-enhanced coronary artery bypass surgery. J Thorac Cardiovasc Surg. 1999; 117: 1212-1215 Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar

Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience

Background. Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. Methods. Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. Results. Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. Conclusions. The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.

Three-dimensional video and robot-assisted port-access mitral valve operation

Background. In order to minimize surgical trauma, video-assisted mitral valve operation has been started using the Port-Access technique with the addition of a three-dimensional visualization system (Vista Cardiothoracic Systems Inc, Westborough, MA) and a voice-controlled camera-holding robotic arm (Aesop; Computer Motion Inc, Goleta, CA).Methods. Port-Access mitral valve replacement or repair (PAMVR) was undertaken using an endovascular cardiopulmonary bypass (CPB) system. Fifty patients underwent Port-Access mitral valve replacement or repair. A three-dimensional thoracoscope was inserted allowing complete three-dimensional projection of the mitral valve (Vista). In the last 20 patients, the camera was attached to a robotic arm (Aesop), which allowed stabilization and voice-activated movement of the camera. Mitral valve repair was performed in 26 patients, and the valve was replaced in 24 patients with a mechanical valve prosthesis.Results. Median time of operation was 4.2 hours, aortic cross-clamp time 83 minutes, CPB time 125 minutes, intensive care unit stay 1.5 days and hospitalization 9.0 days. Three months follow-up was complete in 40 patients, with 34 patients (85%) in New York Heart Association class I and 6 patients in class II. Mortality was 0% and rate of reoperation was 2%, with a follow-up time up to 1.5 years postoperatively.Conclusions. Using three-dimensional video and robotic assistance, it was possible to minimize the length of skin incision, but at the same time to optimally visualize the whole mitral valve apparatus in order to perform true Port-Access mitral valve operation, including various repair techniques.

Minimally invasive video-assisted mitral valve surgery: from Port-Access towards a totally endoscopic procedure.

Right thoracotomy is an alternative to mid-sternotomy for left atrium access. The Port-Access approach is an option that reduces the skin incision and obviates rib spreading. From February 1997 until November 1999, 121 patients underwent mitral valve surgery through a right antero-lateral thoracotomy using the Heartport cardiopulmonary bypass (CPB) system. Mean age was 60 years (31-84). Most patients had normal ejection fractions and were in NYHA Class II or III. Seventy-five patients had valve repair (62%) and 46 (38%) had valve replacement. Pathologies were myxoid (n = 80), rheumatic (n = 30), chronic endocarditis (n = 5), annular dilatation (n = 3), sclerotic (n = 1), ingrowing myxoma (n = 1), and one closure of a paravalvular leak. Two patients had conversion to sternotomy for aortic dissection (one died) with the Endo-Aortic Clamp, and two others for peripheral vascular problems. One patient died at postoperative day 1 after reoperation for failed repair, another with double valve surgery on postoperative day 4 after two revisions for bleeding. Twelve underwent revision for bleeding (10%). Three had prolonged ICU stay for respiratory insufficiency. Two late valve replacements for endocarditis occurred. Echographic control revealed residual insufficiencies (grade 1-2) in two valvular repairs. There were neither paravalvular leaks nor myocardial infarcts. There were no cerebrovascular accidents due to embolic phenomena. Mean ICU and hospital stay were 2.1 and 8.7 days, with a major difference between the first 30 patients and those who followed. Port-Access mitral valve surgery can be a valid alternative to conventional sternotomy and seems to be an important improvement in minimally invasive cardiac surgery.

Direct aortic cannulation for port-access mitral or coronary artery bypass grafting

A technique is described for direct aortic arterial cannulation during Port-Access mitral valve or coronary artery bypass grafting. Femoral arterial cannulation is avoided, and endoaortic balloon occlusion is used for cardioplegic arrest. To date, excellent results have been obtained in 45 patients.

Minimally invasive mitral valve surgery through right anterolateral minithoracotomy

Background. This study evaluates the feasibility of minimally invasive mitral valve surgery. The aim of the study was to minimize surgical access to achieve better cosmetic results, less postoperative discomfort, and faster recovery. Methods. From September 1997 to October 1998, 76 patients underwent mitral valve surgery through a right anterolateral minithoracotomy at the fourth intercostal space. The mitral valve was either repaired (n = 21) or replaced (n = 55). In all cases, open femoral artery-femoral vein cannulation was used for cardiopulmonary bypass. In 27 cases, an endoluminal aortic clamp was used, but in 49 cases, the aorta was cross-clamped with a transthoracic, sliding-rod-design clamp. Results. There were no approach-related limitations to surgical intervention. Intraoperative transesophageal echocardiography revealed excellent results after valve repair and no paravalvular leak in any patient after mitral valve replacement. Mean duration of intensive care and postoperative hospital stay was 32 ± 5.2 hours and 7 ± 1.1 days, respectively. There were no major complications related to femoral vessel cannulation. In 1 patient, transient neurological problems developed, with subsequent complete recovery. There was one hospital mortality (85-year-old male patient died of upper GI bleeding). Conclusions. Minimally invasive port access mitral valve surgery can accelerate recovery and decrease pain, while maintaining overall surgical efficacy. It also provides better cosmetic results to our patients, and now it has become our standard approach for isolated mitral valve surgery.

Intraoperative rupture of the endoaortic clamp balloon in a patient undergoing port-access mitral valve repair

A 66-year-old man (t65 cm, 71 kg) had a 10-year history of mitral valve disease with minimal symptoms. Over the last year, he developed increased shortness of breath and fatigue with physical activity; in the last several months, he was unable to climb a flight of stairs without dyspnea. He underwent a cardiac catheterization, which showed a mildly dilated left ventricle (LV) with an estimated ejection fraction of 83%, 3 + to 4+ mitral regurgitation with a flail posterior mitral leaflet, and a mean pulmonary capillary wedge pressure of 13 mmHg, increasing to 24 mmHg with a V wave to 45 mmHg. Coronary anatomy was normal. He was referred for mitral valve repair or replacement, and a Port-Access, minimally invasive procedure using the Heartport EndoCPB system (Heartport Inc, Redwood City, CA) was planned, The patient was admitted on the same day of surgery. Bilateral radial artery catheters and a pulmonary artery catheter (Swan-Ganz; BaxterEdwards Inc, Deerfield, IL) were inserted. Midazolam, 5 rag, was administered intravenously for sedation. On arrival in the operating room, arterial blood pressure was 125165 mmHg (mean arterial pressure, 80 mmHg); mean pulmonary artery pressure, 30 mmHg; cardiac index, 2.2 L/min/m 2, and heart rate, 60 beats/rain. After preoxygenation, general anesthesia was induced with fentanyl, 500 pg; midazolam, 5 rag; and cisatracurium, 16 mg. The trachea was intubated, and the lungs were ventilated with isoflurane in oxygen. A biplane transesophagoal echocardiography (TEE) probe (Hewlett-Packard, MA) was inserted. The baseline two-dimensional and color-flow Doppler examination confirmed severe mitral regurgitation and valvular changes suggestive of myxomatous degenerative disease, with ruptured chordae and a flail posterior leaflet. The aortic valve appeared normal without regurgitant flow, and the ascending and descending parts of the thoracic aorta were without echocardio~:aphic evidence of significant atheromatous disease. Access to the heart was achieved through a 6-era submammary incision, and the chest was entered through the fourth right intercostal space. The left femoral vessels were exposed through a groin incision, and after systemic anticoagulation with heparin, the Heartport Endoarterial Return cannula was inserted into the femoral artery. A guidewire was advanced from the femoral vein to the right atrium, visualized by TEE, and the Heartport Endovenous Drainage cannula was advanced into the fight atrium with the tip at the superior caval atrial junction. The Heartport Endoaortic Clamp was advanced over a guidewire and positioned in the ascending aorta with the tip slighdy above the sinotubular ridge, as seen by TEE. The surgeon inserted a retrograde cardioplegia catheter through a right atrial purse-string cannulation site into the coronary sinus, guided by TEE and pressure waveform.