Results:
A 60-year-old male with enterococcus faecalis bacteremia, mitral valve endocarditis, and very large mobile mass on the mitral valve underwent minimally invasive mitral valve replacement with 29 mm Magna Ease pericardial valve via right mini-thoracotomy (RMT). Due to severe atherosclerosis in the iliofemoral vessels, direct aortic access was needed through the chest. Two purse-string stitches were placed in the standard fashion through the RMT incision and then pulled out of the chest through a 12-mm port placed in the second intercostal space. Using the Seldinger technique, a guidewire was introduced into the distal ascending aorta within the pursestring via a needle placed through the RMT. The wire was also pulled out through the port. After serial dilation over the wire, a 20-French cannula was advanced into the aortic arch and secured to the purse-string sutures. TEE confirmed the position of the wire and cannula in the aortic arch. Cardiopulmonary bypass was initiated and antegrade cardioplegia catheter was placed in the ascending aorta. Surgery proceeded in the usual fashion. After excising the infected valve, a 29 mm pericardial valve was implanted using Cor-Knot device. After de-airing, aortic root vent was removed and the site was secured with a Cor-Knot (Figure 1A and 1B). The patient was weaned off cardiopulmonary bypass. Aortic cannula was removed and the aortotomy purse-string sutures were secured separately with two additional Cor-Knots through the port under vision (Figure 2). There was no bleeding from the cannulation or the root vent site. Patient was discharged from hospital in 15 days after undergoing femoral-to-femoral bypass and iliofemoral endarterectomy for lower extremity ischemia on post-op day 8.