In 1998, Mohr et al. reported the Leipzig University experience using port-access technology, which read more was based on endoaortic balloon occlusion (EABO) rather than direct aortic clamping [10]. The next major development was the introduction of a voice-controlled robotic camera arm (AESOP 3000, Computer Motion Inc., Santa Barbara, CA, USA) which allowed precise tremor-free camera movements with less lens cleaning. This technology translated into reduced cardiopulmonary bypass (CPB) and cross-clamp (XC) times [11, 12] and enabled even smaller incisions with better valve and subvalvar visualization. The next major leap in the evolution of MIMVS was the development of robotic telemanipulation, and in 1998 Carpentier et al. [13] performed the first completely robotic mitral valve repair using the Da Vinci Surgical System (Intuitive Surgical, Inc.

, Sunnyvale, CA). An important adjunct in the evolution of mini-valve surgery (mini-VS) is the parallel progress in perfusion technology [14]. First, smaller, nonkinking arterial and venous cannulae have been combined with vacuum-assisted venous drainage to allow maximal space use provided by the smaller incisions. Second, the implantation of transjugular coronary sinus catheters provides cardiac protection via retrograde cardioplegia. Third, the application of carbon dioxide (CO2) into the operating field limits intracardiac air (to reduce air embolism), and finally intraoperative transesophageal echocardiography allows for real-time monitoring of cardiac distention, deairing, and cannula placement [15].

Thus, MIMVS has evolved into a routinely performed operation with excellent results in many specialized centers [14, 16�C18]. Minimally invasive valve surgery evolved through graded levels of difficulty with less exposure and to a progressive reliance on video assistance. Loulmet and Carpentier classified these levels of minimally invasive cardiac surgery as shown in Box 1 (Figure 1). Current patient selection is shown in Box 2 [19]. Figure 1 Level 2 minimally invasive approach (4�C6cm incision). Box 1 Levels of ascent in minimally invasive cardiac surgery. Box 2 Current patient selection: videoscopic or video-assisted mitral valve surgery. The type of the musculoskeletal incision remains Carfilzomib central to the discussion around minimally invasive cardiac surgery. A wide variety of modified small sternal, parasternal, and minithoracotomy incisions are used to access the cardiac valves. Although many surgeons prefer the hemisternotomy approach, a right minithoracotomy yields excellent exposure for both direct vision and videoscopic mitral valve access [19]. By the mid-1900s, parasternal and transsternal approaches were being described by Navia and Cosgrove [6] and Cohn et al. [7].