In cases of severe atherosclerosis of the ascending aorta, alterations in the standard surgical technique are mandatory. We report mitral valve replacement and coronary artery bypass grafting in a patient with a severely atherosclerotic aorta. Cardiopulmonary bypass was conducted via an arterial cannula in the femoral artery and two single venous cannulas. Coronary artery bypass grafting was performed using bilateral internal thoracic arteries with beating heart in normothermia. The mitral valve was replaced with a mechanical prosthesis during hypothermic fibrillatory arrest.