Despite major changes in the demographic profile of the surgical population with an increase in the proportion of older patients undergoing cardiac surgery presenting multiple risk factors, the peri-operative mortality and morbidity have declined significantly. These improvements are attributed in part to better management of anesthesia and newer surgical techniques. Conventional open-heart surgery is associated with considerable physiological and psychological adverse effects as a result of the general anesthesia, midline sternotomy, and the use of cardiopulmonary bypass. In recent years, cardiac surgery has advanced by leaps and bounds, most notably by the development of less invasive surgery including minimally invasive direct coronary artery bypass, off-pump surgery, and totally endoscopic with or without robotic assistance. Minimally invasive cardiac surgery has been proposed to reduce surgical trauma, decrease morbidity, lower the procedural costs, and increase patient satisfaction. Patients undergoing minimally invasive surgery have less pain, require less use of blood products, leave the hospital sooner, and return to preoperative functional levels sooner. However, minimally invasive cardiac surgery presents more technical difficulties, a learning curve, and is accompanied by significant surgical hurdles. Along with the development of new surgical techniques and skills, the cardiac anesthesiologist is undoubtedly facing new challenges. Minimally invasive surgery requires a carefully orchestrated coordination of efforts between the surgeon, perfusionist, and anesthesiologist.