However, their disadvantages included femoral CPB cannulation, ligation of the right internal thoracic artery, occasional chest wall instability, and difficult conversion to full sternotomy. http://www.selleckchem.com/products/U0126.html In 1997, Cohn et al. [7] presented 84 minimally invasive cases (41 aortic and 43 mitral) using a right parasternal incision and excising the third and fourth costal cartilages. Interestingly, greater patient satisfaction, a decrease in postoperative atrial fibrillation (AF), and overall lower costs were found [7]. Later, Greelish et al. [20] primarily used a lower mini-sternotomy for mini-MVS with excellent results. Chitwood et al. [21] designed a new aortic clamp that allows transthoracic aortic occlusion. Video assistance has also been used for mini-MVS through small thoracotomies [9, 16, 17].

Although there are highly encouraging results using a right thoracotomy, several disadvantages exist, including peripheral CPB cannulation, the potential need for a double-lumen endotracheal tube, and occasional difficulty with MV exposure [16]. In contrast to this, the Leipzig Group has shown excellent results with their 5-6cm right lateral minithoracotomy under video assistance with peripheral femoral cannulation (Figure 2), direct transthoracic aortic clamping and with single endotracheal tube (Figure 3), and use of cannulation of right internal jugular vein for concomitant tricuspid valve procedures [22, 23]. Several groups strongly advocate for intra-aortic balloon occlusion for minimally invasive and robotic mitral surgery [24�C27]. Most commonly these devices are introduced as retrograde through the femoral artery.

The occlusive balloon is usually positioned under echocardiographic guidance just above the sinotubular junction, and balloon has the potential hazard of migration either into the arch with neurological complications or to the left ventricle with resultant ventricular dysfunction. Balloon occlusion may be advantageous compared to the transthoracic clamp method when there is limited access to the aorta. Aortic dissection is a feared complication of using the endoballoon, but experience with this technique dramatically reduces the risk of this adverse event. However, some group demonstrated increased morbidity, cost, and operative/cross-clamp time when the endoballoon technique was used for mitral valve surgery [28].

Telemanipulators, robotics that allow a hand-like mechanism to be controlled by a human operator, were first used in Paris, France, by Carpentier et al. [8] and Falk et al. [12] in Leipzig, Germany. Telemanipulator-supported operations, which involve femoral cannulation and direct or endoluminal aortic clamping, have Anacetrapib been used and propagated by Chitwood et al. [9, 18] and others [29, 30], who claim that this technique could be safely and effectively used [7].