Comment
The development of minimally invasive mitral surgical approaches and the concomitant anesthetic upskilling that has been required has resulted in a broader range of tools at the disposal of cardiac surgical teams approaching cases such as these. Advantages of using the endoballoon in this setting are shorter DHCA time, excellent myocardial protection and complete decompression of the left ventricle during re-entry. Whilst this approach has been reported in several other publications, this case is unique due to the added complication of patent coronary grafts (4). Pre-procedural CT imaging was utilized to identify an anatomical landmark which could be used on TEE to position the endoballoon relative to the patent grafts. The approach facilitated an excellent recovery. Knowledge of the balloon length is critical for precise placement and identification of a ‘landing zone’ during cases with patent proximal coronary anastomoses. We believe the endoballoon strategy is easily replicated in centers with an active minimally invasive cardiac surgical program.