Introduction Minimally invasive approach through a right mini-thoracotomy is a worldwide used procedure for mitral valve surgery. Aortic occlusion is one the most important open discussion in minimal incision valve surgery. Different techniques have been described during the last years and all have shown benefits and drawbacks. In this retrospective study we define a standard protocol to improve the safety of aortic clamping using a intra-aortic occlusion device in order to reduce related complications. Methods Fiftytwo patients (26 male and 26 female, mean age 62 ± 5 years) underwent cardiac surgery through a right antero-lateral minithoracotomy in our cardiac surgery department. The following surgical procedures have been performed: 32 mitral valve repairs, 4 atrial mixoma excisions, 16 mitral valve replacements. In 7 cases a combined tricuspid valve repair has been performed. In all cases a intra-aortic occlusion device was used for aortic clamping and cardioplegia. Continuous transesophageal three-dimensional echocardiography was performed to confirm the correct position of the venous cannulas and of the intra-aortic occlusion device. In particular, simultaneous multi-plane three-dimensional echocardiography imaging (dual screen simultaneously displaying two real-time images) was acquired to detect the intra-aortic device location in the ascending aorta, the inflation of the balloon, the complete occlusion of the aorta, the delivery of the cardioplegia and to visualize the origin and the blood flow in the right coronary artery. A bilateral upper extremity invasive arterial pressure monitoring has been detected in all cases. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. Neuromonitoring was performed through bilateral cerebral oximetry and transcranial color Doppler. Results The analysis performed among 52 patients has shown no incidence of aortic dissection, no neurological damage type 1 and no myocardial ischemia. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure. Discussion In our opinion, the combined use of transesophageal simultaneous multi-plane three-dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry may be accepted as a standard protocol in order to reduce adverse events and complications related to the use of the intra-aortic occlusion device. Minimally invasive approach through a right mini-thoracotomy is a worldwide used procedure for mitral valve surgery. Aortic occlusion is one the most important open discussion in minimal incision valve surgery. Different techniques have been described during the last years and all have shown benefits and drawbacks. In this retrospective study we define a standard protocol to improve the safety of aortic clamping using a intra-aortic occlusion device in order to reduce related complications. Fiftytwo patients (26 male and 26 female, mean age 62 ± 5 years) underwent cardiac surgery through a right antero-lateral minithoracotomy in our cardiac surgery department. The following surgical procedures have been performed: 32 mitral valve repairs, 4 atrial mixoma excisions, 16 mitral valve replacements. In 7 cases a combined tricuspid valve repair has been performed. In all cases a intra-aortic occlusion device was used for aortic clamping and cardioplegia. Continuous transesophageal three-dimensional echocardiography was performed to confirm the correct position of the venous cannulas and of the intra-aortic occlusion device. In particular, simultaneous multi-plane three-dimensional echocardiography imaging (dual screen simultaneously displaying two real-time images) was acquired to detect the intra-aortic device location in the ascending aorta, the inflation of the balloon, the complete occlusion of the aorta, the delivery of the cardioplegia and to visualize the origin and the blood flow in the right coronary artery. A bilateral upper extremity invasive arterial pressure monitoring has been detected in all cases. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. Neuromonitoring was performed through bilateral cerebral oximetry and transcranial color Doppler. The analysis performed among 52 patients has shown no incidence of aortic dissection, no neurological damage type 1 and no myocardial ischemia. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure. In our opinion, the combined use of transesophageal simultaneous multi-plane three-dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry may be accepted as a standard protocol in order to reduce adverse events and complications related to the use of the intra-aortic occlusion device.