The minimally invasive Port-Access (Heartport, Redwood City, CA) approach in mitral-valve operations originally required femoral arterial cannulation, which is considered a disadvantage, especially in patients with peripheral vessel disease. In this study 20 patients were prospectively randomized into 2 groups, to undergo either standard femoral (group A) or direct aortic cannulation (group B). Pre- and postoperative data as well as markers for myocardial damage were assessed. Postoperatively, patients of group B showed lower levels of damage, indicating that direct aortic cannulation might provide better myocardial protection. Furthermore, the direct aortic cannulation technique may eliminate complications associated with the standard femoral artery cannulation.