The operative set-up consists of a general anesthesia, double-lumen endotracheal tube, transesophageal echocardiogram, and monitoring of EKG, pulse oximeter and pressure. The patient is slightly tilted on the left side to optimize the surgical exposition. A jugular venous cannula is positioned by the anesthesiologist, and the right femoral vessels are isolated and cannulated for bicaval cardiopulmonary bypass institution. An anterolateral thoracotomy is performed in the IV right intercostal space with a soft tissue retractor and a costal retractor. A trocar is inserted in the IV intercostal space for the camera and another one is placed in the VI intercostal space for CO2 insufflation. A horizontal pericardiectomy is done circa 3 cm above the phrenic nerve. After suspending the pericardium, also the right atrial appendage is suspended to expose the aortic root, where a vent is placed for cardioplegia delivery and deairing.