Cerebral embolisation with underlying left heart valve endocarditis remains an indication for urgent cardiac repair. Nonetheless, open heart surgery early after neurosurgery in a patient with sepsis and multiorgan dysfunction (cerebral, cardiac, pulmonary, renal) is challenging. In addition, revision surgery after sternotomy increases the risk for surgical complications and anticoagulation. Also, prolonged major surgery (double valve repair and aortocoronary bypass) under sepsis may further increase the risk for postoperative cerebral and thoracic bleeding, systemic inflammatory response and multiorgan failure.
Nonetheless, minimally invasive approaches have been shown to reduce the risk of major cardiac surgery,  although they are not yet validated for complex cardiac revision surgery and complicated endocarditis.
The present case demonstrates the suitability of a right lateral mini thoracotomy for the first time. It allows adequate exposure and handling of both atrioventricular valves and of the right coronary artery in a revision setting.
As previously described , the patent and opened LAD bypass did not cause any difficulties for rush cardiac arrest and reperfusion. The exposure of both atrioventricular valves can be easily achieved via right lateral mini-thoracotomy, and video-assistance allows adequate anatomic reconstruction of the valves (Fig. 4) with outstanding postoperative results (Fig. 6). The implantation of a bypass on the right coronary can be performed without any difficulties in combination with a valve implantation as also described above .
Therefore, the present case reveals not only the advantages of minimal access surgery such as limited adhesion preparation, reduced risk of hemodynamic instability, better wound healing and feasibility for tracheostomy, but also a safer outcome due to reduced surgical trauma, less bleeding and need for transfusion, lower risk for wound infections, less pain and favorable cosmesis. Additionally, faster recovery of pulmonary function, early mobilization, shorter hospital stays and decreased healthcare costs, make this a preferred approach for the surgeons.
The present clinical case demonstrates that the advantages arising from the procedural features enable the minimally invasive performance to generate a good outcome in complicated high-risk cardiac revision surgery.
The COVID-19 pandemic and prophylactic patient isolation significantly slowed down the efficacy of pulmonary weaning and mobilisation, and prolonged the demand for ICU treatment, did not however heighten postoperative morbidity by increasing dysfunction of other organs and systems.
In conclusion, the present case demonstrates that the minimally invasive approach can safely be used in complicated cases of mitral valve endocarditis with associated tricuspid and right coronary disease. Multimorbidity and previous coronary revascularisation are not contraindications, and a minimally invasive approach might minimize the risk for intracranial bleeding after recent neurosurgery. Aspects of minimal access surgery such as limited adhesion preparation, better wound healing, preservation of pulmonary function and feasibility for tracheostomy are advantageous. Efforts should be made to further develop these procedures, making their application available and safe for a larger population of patients.