Evaluation of Activated Clotting Times With a Heparin Reversal Protocol Designed to Conserve Protamine During Drug Shortages: A Retrospective, Cohort Study.

OBJECTIVE: To retrospectively evaluate a protamine conservation approach to heparin reversal implemented during times of critical shortages. This approach was aimed at maintaining access to cardiac surgical services. SETTING: In-patient hospital setting. PARTICIPANTS: Eight hundred-one cardiac surgical patients>18 years old. INTERVENTIONS: Patients undergoing cardiac surgery who received >30,000 U of heparin were given a single fixed vial protamine dose of 250 mg or a standard 1 mg of protamine to 100 U of heparin ratio-based dose to reverse heparin. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was differences in post-reversal activated clotting times between the 2 groups. The secondary endpoint was differences in the number of protamine vials used between the 2 reversal strategies. The first activated clotting times values measured after initial protamine administration were not different between the Low Dose and Conventional Dose groups (122.3 s v 120.6 s, 1.47 s, 99% CI -1.47 to 4.94, p = 0.16). The total amount of protamine administered in the Low Dose group was less than that in the Conventional Dose group (-100.5 mg, 99% CI -110.0 to -91.0, p < 0.0001), as were the number of 250 mg vials used per case (-0.69, 99% CI -0.75 to -0.63, p < 0.0001). The mean initial protamine doses between groups were 250 mg and 352 mg, p < 0.0001. The mean protamine vials used were 1.33 v 2.02, p < 0.0001. When the calculations were based on 50 mg vials, the number of vials used per case in the Low Dose group was even less (-2.16, 99% CI -2.36 to -1.97, p < 0.0001).) CONCLUSIONS: Conservation measures regarding critical medications and supplies during times of shortages can maintain access to important services within a community.

Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors.

OBJECTIVES: To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery. DESIGN: A retrospective study. SETTING: At an academic university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery. INTERVENTIONS: SGLT2i use versus no SGLT2i use. MEASUREMENTS AND MAIN RESULTS: The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p = 0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p = 0.22), 30-day mortality (1.9% v 0.7%, p = 0.31), or sternal infections (0.0% v 0.3%, p = 0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p = 0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p = 0.042). Mortality (0.0% v 2.2%, p = 0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare. CONCLUSIONS: Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.

Size does matter: Yet BMI extremes are manageable in minimally invasive cardiac surgery.

The obesity paradox has been recently challenged in the literature to spotlight a vague and ill-defined relationship between obesity extremes and cardiac morbidity and mortality. Patient size and incision size both remain important determinants of outcomes. Today, with obesity rates rising around the world, extremely obese patients require experienced teams and substantially improved care.

Surgical versus transcatheter aortic valve replacement: Impact of patient-prosthesis mismatch on outcomes.

BACKGROUND: The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis-patient mismatch (PPM). As the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence. METHODS: For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed. RESULTS: The impact of PPM on clinical outcomes in aortic valve replacement has not been clear as multiple studies failed to report PPM incidence. However, the PPM outcomes after SAVR vary more widely than after TAVR, ranging from 8% to 80% in SAVR and from 24% to 35% in TAVR. Incidence of severe PPM following redo SAVR ranges from 2% to 9% and following valve-in-valve TAVR is from 14% to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates. CONCLUSIONS: The gap between valve performance and clinical outcomes in SAVR and TAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both SAVR and TAVR.

Minimally invasive, simplified double-layer left atrial appendage closure.

The left atrial appendage (LAA) has been identified as a site of thrombus formation in the heart and as a source of embolism in patients with atrial fibrillation, leading to stroke. Studies suggest that LAA closure may reduce the risk for stroke and the need for anticoagulation; conversely, incomplete closure can increase the stroke risk almost 12-fold. Because open heart surgery is associated with increased risk for subsequent stroke, surgeons generally prefer to close the LAA during heart surgery, as recommended in current atrial fibrillation management guidelines. Building on trends toward minimally invasive approaches in cardiac surgery, we developed a simple, unique, and reproducible method for complete LAA closure during mitral valve surgery that has proven to be safe and efficacious: Our first three patients remained completely free from stroke and minor neurological manifestations 27 months after surgery.

Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches.

Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.

Cardiac surgery in the time of the novel coronavirus: Why we should think to a new normal.

On 11 March 2020, the World Health Organization declared the SARS-CoV-2 outbreak a pandemic. At the time of writing, 24 May 2020 more than 5 million individuals have been tested positive and the death toll was over 330 000 deaths worldwide. The initial data pointed out the tight bond between cardiovascular diseases and worse health outcomes in COVID19-patients. Epidemiologically speaking, there is an overlap between the age-groups more affected by COVID-related death and the age-groups in which Cardiac Surgery has its usual base of patients. The Cardiac Surgery Departments have to think to a new normal: since the virus will remain endemic in the society, dedicated pathways or even dedicated Teams are pivotal to treat safely the patients, in respect of the safety of the health care workers. Moreover, we need a keen eye on deciding which pathologies have to be treated with priority: Coronary artery Disease showed a higher mortality rate in patients affected by COVID19, but it is, however, reasonable to think that all the cardiac pathologies affecting the lung circulation-such as symptomatic severe mitral diseases or aortic stenosis-might deserve a priority access to treatment, to increase the survival rate in case of an acquired-Coronavirus infection later on.

Left subclavian to descending aorta bypass: A less invasive extra-anatomical solution for a type A interrupted aortic arch.

Interrupted aortic arch (IAA) is defined as a discontinuity of the aortic lumen from the aortic arch to the descending aorta. The incidence of this congenital malformation is three per million live births. It represents about 1.5% of congenital cardiac abnormalities. The classification system for IAA is divided into three distinct categories-type A: interruption of the lumen distal to the left subclavian artery, occurring in 43% cases; type B: interruption between the left carotid and left subclavian arteries, occurring in 53% cases (the most common); and type C: interruption between the innominate and left carotid, occurring in 4% cases. We describe the case of a 47-year-old woman who had a symptomatic type A IAA. A single-stage extra-anatomic bypass was performed between the left subclavian and the descending thoracic aorta using a 14 mm Dacron graft. The use of this approach is an option to solve this challenging clinical problem.

A Staged Approach of Proximal Left Anterior Descending Coronary Artery Percutaneous Intervention Followed by Minimally Invasive Valve Surgery.

BACKGROUND AND AIM OF THE STUDY: A subset of patients requiring coronary revascularization of the proximal left anterior descending coronary artery (LAD) and valve surgery may benefit from a staged approach, rather than combined median sternotomy coronary artery bypass graft (CABG) and valve surgery. METHODS: A retrospective evaluation was made of the outcomes of patients with significant proximal LAD and valvular heart disease undergoing a staged approach of percutaneous coronary intervention (PCI) followed by minimally invasive valve surgery (MIVS) at the authors' institution between February 2009 and April 2014. A Kaplan-Meier analysis was performed to estimate mid-term survival. RESULTS: A total of 68 consecutive patients (mean age 75.2 ± 8.9 years) was identified. PCI was performed for one- or two-vessel disease in 76.5% and 23.5% of the patients, respectively. Within a median of 39 days (IQR 11-62 days), 91.2% of patients underwent primary MIVS, and 8.8% underwent re-operative MIVS, of which 58 (85.3%) were single-valve and 10 (14.7%) were double-valve operations. At the time of surgery, 72.1% of the patients were receiving dual anti-platelet therapy. The 30-day mortality was 2.9%. At a mean follow up of 26 ± 16 months, 7.4% of the patients had a non-target vessel acute coronary syndrome, and the survival rate was 88.2%. CONCLUSIONS: Among a select group of patients with proximal LAD and valvular disease, a staged approach of PCI followed by MIVS can be safely performed for primary or re-operative surgery, with excellent mid-term outcomes.

Minimally Invasive Versus Transcatheter and Surgical Aortic Valve Replacement: A Propensity Matched Study.

BACKGROUND: An increasing number of options exist for the treatment of severe symptomatic aortic stenosis. The study aim was to compare short-term outcomes in patients undergoing surgical aortic valve replacement (SAVR), minimally invasive aortic valve replacement (MIAVR), and transcatheter aortic valve replacement (TAVR). METHODS: A multi-institutional retrospective review of 2,571 patients undergoing SAVR (n = 842), MIAVR via right anterior thoracotomy (n = 699) and TAVR (n = 1,030) between 2011 and 2014 was conducted. TAVR patients were further stratified as either transfemoral (TF) or transapical (TA). Propensity matching was performed between MIAVR and SAVR (384 pairs), MIAVR and TA-TAVR (115 pairs), and MIAVR and TF-TAVR (247 pairs). RESULTS: Total numbers of AVR increased between 2011 and 2014. When stratified by procedure type, MIAVR and TF-TAVR accounted for most of the growth, while TA-TAVR and SAVR each experienced a decreased volume. Propensity matched comparisons of SAVR, TF-TAVR, and TA-TAVR versus MIAVR revealed no difference in 30-day mortality. TF-TAVR versus MIAVR revealed that MIAVR had a decreased rate of stroke (0.4% versus 3.6%, p = 0.02) and increased atrial fibrillation (AF; 19.4% versus 4%, p <0.01). When compared to SAVR, MIAVR had a lower incidence of AF (19% versus 32.6%, p <0.01). MIAVR exhibited decreased ventilation time (27.2 versus 134 h, p = 0.03) and intensive care unit time (63.7 versus 92.7 h, p = 0.02) compared to TA-TAVR. CONCLUSIONS: During recent years, MIAVR and TFTAVR have experienced significant growth in volume with near-comparable short-term outcomes, while SAVR and TA-TAVR volumes have declined. These results underscore the importance of surgeons adopting MIAVR and TF-TAVR techniques in order to offer patients optimal outcomes.

Simplified prediction of postoperative cardiac surgery outcomes with a novel score: R2CHADS2.

OBJECTIVE: To compare the accuracy of R2CHADS2, CHADS2, and CHA2DS2-VASc scores vs the Society of Thoracic Surgeons (STS) score as predictors of morbidity and mortality after cardiovascular surgery. METHODS: All patients who underwent cardiothoracic surgery at our institution from January 2008 to July 2013 were analyzed. Only those patients who fulfilled the criteria for STS score calculation were included. The R2CHADS2 score was computed as follows: 2 points for GFR < 60 mL/min/1.73 m(2) (R2), prior stroke or TIA (S2); 1 point for history of congestive heart failure (C), hypertension (H), age ≥75 years (A), or diabetes (D). Area under the curve (AUC) analysis was used to estimate the accuracy of the different scores. The end point variables included operative mortality, permanent stroke, and renal failure as defined by the STS database system. RESULTS: Of the 3,492 patients screened, 2,263 met the inclusion criteria. These included 1,160 (51%) isolated valve surgery, 859 (38%) coronary artery bypass graft surgery, and 245 (11%) combined procedures. There were 147 postoperative events: 75 (3%) patients had postoperative renal failure, 48 (2%) had operative mortality, and 24 (1%) had permanent stroke. AUC analysis revealed that STS, R2CHADS2, CHADS2, and CHA2DS2-VASc reliably estimated all postoperative outcomes. STS and R2CHADS2 scores had the best accuracy overall, with no significant difference in AUC values between them. CONCLUSION: The R2CHADS2 score estimates postoperative events with acceptable accuracy and if further validated may be used as a simple preoperative risk tool calculator.

Tricuspid Valve Repair with Pericardial Tube Placement via a Right Minithoracotomy.

The optimal surgical intervention for tricuspid valve endocarditis remains challenging in the setting of intravenous drug abuse. The situation is often complicated by aggressive bacterial pathogens, an increased risk of reinfection and reoperation, and poor long-term survival, despite a typically younger age at presentation. Herein, the case is presented of a 30-year-old female with infective endocarditis of the tricuspid valve secondary to intravenous drug abuse. The patient underwent minimally invasive tricuspid valve reconstruction utilizing a bovine pericardial tricuspid tube. This is a viable alternative to conventional techniques, and may reduce the risk of reinfection and reoperation, maintain ventriculo-tricuspid integrity, provide structural support, and also be performed via a minimally invasive approach.

Intermediate results of transaortic edge-to-edge repair of the mitral valve in patients undergoing aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the safety and efficacy of a transaortic edge-to-edge mitral valve repair in patients undergoing aortic valve replacement (AVR) who were considered to be at high risk for double-valve surgery. METHODS: All patients deemed to be at high surgical risk for standard double-valve surgery, and who instead underwent AVR with transaortic edge-to-edge mitral valve repair between September 2008 and October 2012 at the authors' institution, were analyzed retrospectively. Intraoperative transesophageal and follow-up transthoracic echocardiography were performed to evaluate adequacy of the repair and to assess for any recurrence of mitral regurgitation (MR). RESULTS: A total of 55 patients (mean age 78.4 +/- 8.4 years) was identified (45 minimally invasive, 10 median sternotomy). All patients were in NYHA class III-IV. The aortic valve lesion was classified as stenosis (n = 45), insufficiency (n = 6), or prosthetic valve insufficiency (n = 4), and the mitral valve lesion as functional (n = 16), degenerative calcification (n = 27), or rheumatic (n = 12). There were four deaths (7%). The median total hospital length of stay was 7 days (IQR 6-11 days). The median preoperative versus postoperative MR grade was moderate-to-severe (3+) (IQR 3-4+) versus 0 (IQR 0-1+) (p < 0.001). The median time to follow up echocardiography was 6.5 months (IQR 0.8-12 months). The median preoperative and postoperative versus follow up MR grades were 3+ (IQR 3-4+) versus 1+ (IQR 0-1+) (p < 0.001), and 0 (IQR 0-1+) versus 1+ (IQR 0-1+) (p = 0.004), respectively. CONCLUSION: In high-risk patients undergoing AVR with grade 3-4+ MR, a transaortic edge-to-edge mitral valve repair may be a safe and effective alternative to conventional double-valve surgery. However, longer-term data are needed to verify this proposal.

Right anterior minithoracotomy versus median sternotomy surgery for native mitral valve infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: While concomitant medical and surgical therapy has improved the treatment of infective endocarditis (IE), mortality and postoperative complications remain high. A minimally invasive approach to mitral valve surgery has been associated with decreased morbidity and mortality in high-risk populations. The study aim was to analyze the feasibility of a minimally invasive approach to valve surgery for native mitral valve IE. METHODS: All heart operations performed between January 2008 and April 2013 at the authors' institution were reviewed retrospectively. The operative times, intensive care unit (ICU) and hospital lengths of stay, postoperative complications, and in-hospital mortality of patients who underwent minimally invasive surgery via a right anterior minithoracotomy for native mitral valve IE were compared to those of a cohort which underwent median sternotomy. A Kaplan-Meier analysis was performed to compare long-term survival between the cohorts. RESULTS: A total of 50 patients was identified (22 minithoracotomy, 28 median sternotomy). The baseline characteristics, mitral valve pathology and disease burden (annular abscess, cusp perforation, vegetation size, chordal rupture) were similar between the groups. There was no difference in the rate of active versus healed disease. Patients who underwent a minithoracotomy had fewer postoperative composite complications (41% versus 75%, p = 0.02), mainly driven by a decreased incidence of sepsis (0% versus 21%, p = 0.02), as well as less use of intraoperative blood products (59% versus 93%, p = 0.004), higher rates of mitral valve repair (55% versus 25%, p = 0.03), and a shorter ICU length of stay (56 versus 114 h, p = 0.009). Repair of the mitral valve was associated with a decreased risk of postoperative composite complications (OR 0.16, 95% CI 0.04-0.71, p = 0.02). At 2.5 years postoperatively, survival was estimated at 80% and 68% in the minithoracotomy and median sternotomy groups, respectively (p = 0.33). CONCLUSION: A right anterior minithoracotomy approach for native mitral valve IE provides a safe and feasible alternative to conventional median sternotomy surgery, with improved outcomes conferred by valve repair compared to replacement.

Minimally invasive aortic valve replacement in octogenarians performed via a right anterior thoracotomy approach.

BACKGROUND AND AIM OF THE STUDY: A significant number of patients aged > or =80 years are denied aortic valve surgery due to the assumption of poor outcomes with surgery. The study aim was to evaluate the outcomes of minimally invasive aortic valve replacement (AVR), performed via a right anterior thoracotomy approach, in octogenarians. METHODS: A retrospective review was conducted of all minimally invasive isolated AVRs in patients aged > or =80 years performed at the authors' institution between February 2009 and April 2014. The operative times, postoperative complications, hospital length of stay and mortality were analyzed. RESULTS: A total of 255 consecutive patients (133 males, 122 females; mean age 83.5 +/- 3 years) was identified. The mean left ventricular ejection fraction was 57 +/- 10%, and 31 patients (12.2%) had prior cardiac surgery. The median predicted Society of Thoracic Surgeons mortality score was 3.2% (IQR 2.4-4.4%). Postoperatively, four patients (1.6%) had cerebrovascular accidents, 38 (14.9%) had prolonged ventilation, four (1.6%) required reoperation for bleeding, and eight (3.1%) had acute kidney injury. The median intensive care unit length of stay was 48.5 h (IQR 27-92 h) and the postoperative length of stay was 7 days (IQR 5-9 days). The 30-day mortality was 3.1% (n=8), and the combined end point of morbidity and mortality was 19.2% (n=49). The all-cause mortality at one and three years was 6.7%, and 10.2%, respectively. CONCLUSION: Minimally invasive AVR in octogenarians, performed via a right anterior thoracotomy approach, is associated with a low morbidity and mortality. This applies to both primary or reoperative surgery.

Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy.

Objective: Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR). Methods: We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery. Results: Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease. Conclusions: A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry.

Objective: Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry. Methods: From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied. Results: Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV (P < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; P < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; P < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; P = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; P = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; P = .02), and acute kidney injury (13.8% vs MV: 10%; P = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation. Conclusions: cTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.

Minimally invasive transaortic edge-to-edge repair of the mitral valve.

Clinically significant mitral regurgitation is often found in conjunction with severe aortic valve stenosis. Adding mitral valve surgery to an aortic valve replacement (AVR) increases the operative risk. However, this increased operative risk may be reduced if, during AVR, a standard double-valve surgery is avoided and AVR isperformed instead with a transaortic edge-to-edge repair of the mitral valve. Utilizing a minimally invasive approach with this technique may further reduce the operative risk when compared to a median sternotomy approach. The procedural technique for this surgery is described in the present report.