This is the first documented mini-thoracotomy supra coronary replacement of the ascending aorta with a graft and AVR that I am aware of. My initial intent was to only replace the AV. Upon entering the chest, I noticed that the aorta was slightly larger than expected. I did not feel that leaving the aorta alone or tailoring it would be acceptable. I decided to replace it with a hemashield graft. I do not believe that it would have been technically possible if the aortic enlargement extended to the arch. In this case, circulatory arrest would be required. One technical point is that once the distal anastomosis is performed, the clamp should be repositioned on the graft and the posterior suture line checked for bleeding.