The Starfish™ Heart Positioner aids off-pump coronary artery surgery in adult patients by providing posterior cardiac exposure without incurring hemodynamic instability. Herein, we describe its use in a 17-month-old girl who had a right coronary artery fistula that drained to the right ventricle. Use of the device enabled exposure that afforded closure of the fistula without cardiopulmonary bypass. The patient was discharged from the hospital 2 days postoperatively. Six weeks later, she was well, and echocardiography showed no residual fistulous flow. © 2009 by the Texas Heart® Institute.