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None of our patients had postoperative mitral regurgitation of more than 1+ over a mean follow-up of 2 years. The string puppet technique improves exposure of mitral and tricuspid valves in totally endoscopic cardiac surgery. It is safe, effective, easy to perform, and inexpensive. The string puppet technique improves exposure of mitral and tricuspid valves in totally endoscopic cardiac surgery. It is safe, effective, easy to perform, and inexpensive. To estimate the incidence-based, lifetime costs of health care and productivity losses