While performing a minimally invasive AVR, I recently encountered a case  in which I, nor the Cardiologist appreciated the LM stenosis and the significant calcification surrounding the Left Main.  While giving a dose of antegrade cardioplegia, I noticed that the left main was unusually small.  After review of the cath films again, I noticed that the catheter did not completely engage the LM.  It constantly popped out. I knew at this point that the LAD needed to by bypassed. My choices were to perform a sternotomy or attempt to bypass the LAD from the right mini-thoracotomy incision. He was an elderly patient so I decided to harvest a segment of vein and bypass the LAD. Enclosed are pictures.

This was the mid LAD and I utilized a sponge stick to expose the LAD.  I am not sure if it will be reproducible in all cases but it is a start!!!! I am sure I could not do a LIMA from this approach unless I harvested it from a left sided exposure (I know that there is someone that I trained that did do this).  It does add another incision and layer of complexity so I wonder if it is worth the extra effort?  I would appreciate anyone’s input.