MIMVR has been described elsewhere.1–2 Briefly, a 5-cm incision was made over the fourth rib in the right anterolateral chest. A 4-cm segment of the fourth rib was resected, and the lung was deflated (Fig 2
). Through the open pericardium, the superior vena cava, the right atrium, and the superior pulmonary vein were visualized clearly. Cardiopulmonary bypass was initiated, and the patient was cooled to 26°C. A 10-mm thoracoscopic camera was passed into the chest through a port placed in the third intercostal space midaxillary line. Antegrade and retrograde cardioplegia catheters were placed through the small incision. TEE facilitated placement of the retrograde coronary sinus cannula. Using a specially designed transthoracic aortic cross-clamp percutaneously inserted through a separate stab wound (Scanlan International; St Paul, MN) [Fig 3]
, the aorta was cross-clamped and the heart arrested using cold antegrade and retrograde blood cardioplegia. The interatrial groove was dissected, and left atriotomy was performed. The atrial septum was retracted using a thin malleable retractor anteriorly exposing the mitral valve structures that could be visualized through the thoracoscopic camera as well as directly through the incision. On valve analysis, only annular dilatation was noted. Horizontal mattress sutures (00 Ti-Cron; Davis and Geck; Danbury, CT) were placed in the annulus of the valve. A 34-mm Physio-annuloplasty ring (Edwards CVS Division; Baxter Healthcare; Irvine, CA) was selected based on annular measurement. Sutures were brought out of the incision and placed through the ring. The ring was lowered in place, and all knots were made extracorporeally and then tightened using a specially designed knot tier (Scanlan International; Fig 4
). The heart was de-aired using a combination of aortic root venting and carbon dioxide field flooding. The atriotomy was closed and the cross-clamp released after a total of 108 min. Systemic rewarming was initiated. The heart began to beat spontaneously.