The landscape of cardiac surgery is changing. Advances in endoscopic and other instrumentation procedures such as port access, video instrumentation, and computer-assisted technology are opening new vistas for cardiac surgery. On the immediate horizon is minimally invasive cardiac surgery, also known as keyhole surgery. Imagine a patient not needing a median sternotomy incision or cardiopulmonary bypass. This new type of cardiac surgery is currently being explored at some cardiac surgical centers internationally. This article explores the current state-of-the-art related to minimally invasive direct coronary artery bypass surgery. The operative procedure, implications for perioperative nursing care, likely future technologies, and the research literature on outcomes are also discussed.