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Background Use of minimally invasive approaches for isolated aortic valve or ascending aorta surgery is increasing. However, total arch replacement or aortic root repair through a minimally invasive incision is rare. This study was performed to report our initial experience with surgery of the ascending aorta with complex procedures through an upper mini-sternotomy approach. Methods We retrospectively analyzed 80 patients who underwent ascending aorta replacement combined with complex procedures including hemi-arch, total arch, and aortic root surgeries from September 2010 to May 2018. Using standard propensity score-matching analysis, 36 patients were matched and divided into 2 groups: the upper mini-sternotomy group (n = 18) and the median sternotomy group (n = 18). The preoperative assessment revealed no statistically significant differences between the two groups. Results Hospital mortality occurred in one patient (2.8%). The mini-sternotomy group showed a longer cross-clamping time (160 ± 38 vs. 135 ± 36 min, p = 0.048) due to higher rate of valve-sparing aortic root replacement and total arch repair. The cardiopulmonary bypass time in mini-sternotomy group was shorter than that of full sternotomy group (209 ± 47 min vs 218 ± 62 min, p = 0.595) but fell short of significance. There was no significant difference in lower body hypothermia circulatory arrest time between the two groups (40 ± 10 min vs 48 ± 20 min, p = 0.139). The upper mini-sternotomy group displayed a shorter ventilation time (22 vs. 45 h, p = 0.014), intensive care unit stay (4.6 ± 2.7 vs. 7.9 ± 3.7 days, p = 0.005), and hospital stay (8.2 ± 3.8 vs. 21.4 ± 11.9 days, p = 0.001). The upper mini-sternotomy group showed a lower postoperative red blood cell transfusion volume (4.6 ± 3.3 vs. 6.7 ± 5.7 units, p = 0.042) and postoperative drainage volume (764 ± 549 vs. 1255 ± 745 ml, p = 0.034). The rates of dialysis for newly occurring renal failure, neurological complications, and re-exploration were similar between the two groups (p = 1.000). Conclusion The upper mini-sternotomy approach is safe and beneficial in ascending aorta surgery with complex procedures for aortic dissection, including total arch replacement and aortic root repair.

OBJECTIVE: To compare the midterm outcomes of patients with isolated left anterior descending disease (iLAD) who underwent robotically assisted coronary artery bypass graft (R-CABG) and percutaneous coronary intervention (PCI) with drug eluting stents (DES). METHOD: Clinic data was collected in 223 patients who underwent R-CABG in our hospital between July, 2007 to November, 2014. Cardiology Database System of our hospital was used to identify 4047 patients who underwent PCI with DES for LAD lesion between April, 2011 to November, 2014. Total 496 patients received DES and 108 patients underwent R-CABG after screening. Patients were propensity matched into 108 R-CABG and DES pairs according to vital statistic. Mortality, myocardial infarction (MI), stroke, repeat target lesion revascularization (r-TLR), main adverse cardiac and cerebral events (MACCE), and angina relief were compared across pairs. RESULT: Kaplan-Meier estimates for R-CABG and DES had no significant difference in mortality (p = 1.00), MI (p = .32), Stroke (p = .80), and MACCE (p = .47), but the rate of r-TLR (p = .03) were lower in R-CABG group. Patients who underwent R-CABG had better angina relief (p = .02), lower rate of arrhythmia (p < .001), and recurrent angina (p = .02) after operation compared patients received DES. CONCLUSION: R-CABG offers lower r-TLR rate and better angina relief compared with DES for revascularization in patients with isolated proximal LAD stenosis and there was no difference in mortality, MI, stroke, and MACCE between them.

Introduction: Diffuse coronary artery disease (CAD) has a poor prognosis and many patients are ineligible for conventional coronary artery bypass grafting (CABG). This study evaluated the 12-month outcomes of coronary artery reconstruction and surgical patch angioplasty of the coronary artery for diffuse CAD. Methods: A retrospective cohort study of patients who underwent CABG with surgical patch angioplasty of the coronary artery (reconstruction group) or standard CABG alone (standard group) at the Cardiovascular Surgery Department of the local Hospital between January 2014 and January 2016. Follow-up was censored at 12 months after surgery. Results: Cardiopulmonary bypass and aortic cross-clamping durations were longer in the reconstruction group (n=32) than in the standard group (n=125) (P0.05). In the reconstruction group, one patient died; a vein graft showed occlusion. In the standard group, two patients died; one left internal mammary artery graft and three vein grafts showed occlusion. There were no significant differences in mortality, major adverse cardiovascular and cerebrovascular events, and patency between the two groups (P>0.05). Conclusion: Coronary artery reconstruction and surgical patch angioplasty of the coronary artery can be performed for diffuse CAD. Patient outcomes were not significantly different from those of patients who underwent standard CABG.

Background Level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCT) has been reported in limited series. Objective To report our initial series of level III-IV RA-IVCT with step-by-step procedures and 1-yr outcomes. Design, setting, and participants From November 2014 to January 2018, 13 patients with level III-IV IVC tumor thrombi underwent RA-IVCT with a minimum of 1-yr follow-up. Surgical procedure Level III RA-IVCT requires liver mobilization and clamping of first porta hepatis (FPH), and suprahepatic and infradiaphragmatic IVC. Level IV RA-IVCT requires establishment of cardiopulmonary bypass (CPB). Thoracoscopy-assisted thrombectomy was performed for the intra-atrium part of the thrombus under CPB. Infradiaphragmatic RA-IVCT was completed in a manner similar to that of level III RA-IVCT. Measurements Detailed techniques were described for various scenarios. Baseline and perioperative outcomes were reported, and descriptive statistical analysis was performed. Results and limitations Median operative time was 465 (interquartile range [IQR]: 338–567) min. Median estimated intraoperative blood loss was 2000 (IQR: 1000–3000) ml. The rates of intraoperative blood transfusion and postoperative transformation to the intensive care unit ward were 92.3% and 100%, respectively. Median FPH blocking time was 40 (IQR: 25–60) min and the CPB time was 72 (IQR: 51–87) min. Three cases had grade IV complications, including two vascular injuries that were treated with intraoperative endoscopic sutures and one perioperative death. The perioperative mortality rate was 7.7%. During an 18-mo follow-up, two patients died and one patient progressed. Conclusions Although the risks involved are high, level III-IV RA-IVCT is feasible and serves as an alternative minimally invasive method for selected patients. It also requires more complex techniques and multidisciplinary cooperation. Patient summary We studied the treatment of patients with level III-IV inferior vena cava (IVC) tumor thrombi using a robotic approach. This technique was feasible for well-selected patients. However, level III-IV robot-assisted IVC thrombectomy requires more complex techniques and multidisciplinary cooperation.

Background Robotic cardiac surgery has been proved safe and feasible in dedicated centers. We systematically analyzed the learning curve issues associated with totally endoscopic coronary artery bypass grafting (TECAB) using a stepwise approach by a single surgeon who had successfully performed >650 cases of various types of robotic cardiac surgery at our single center. Methods From January 2007 to March 2013, 230 patients underwent robotic coronary bypass grafting on the beating heart. Of these patients, 90 had successfully undergone beating heart TECAB using the da Vinci S/Si Surgical System without conversion to sternotomy. All beating heart TECAB procedures were completed using the following modules: endoscopic left internal thoracic artery (LITA) harvesting, pericardiotomy and target vessel identification, and anastomosis of the LITA to the target vessel. The perioperative outcomes were compared among 3 quintiles of 30 consecutive patients each and the learning curve results were evaluated. Results No in-hospital mortality or severe morbidity occurred. The comparison among the 3 quintiles showed a significant decrease in operative time ( P = .000), LITA harvesting time ( P = .037), and anastomotic time ( P = .000). A significant learning curve was observed for the operative time [y(min) = 223 − 17 × ln(x); r 2 = 0.217, P = .000]; LITA harvesting time [y(min) = 37 − 3 × ln(x); r 2 = 0.097, P = .003]; and LITA–left anterior descending artery anastomotic time [y(min) = 18 − 2 × ln(x); r 2 = 0.298, P = .000]. No differences were found in the mean transit flow ( P = .102) or perioperative complications among the 3 quintiles. Conclusions Modular-based TECAB procedures can be successfully performed; however, each module has a steep learning curve. A stable and well-trained robotic cardiac team and an experienced cardiac surgeon can achieve good, reproducible results after this substantial learning curve.

Cor triatriatum sinister (CTS) is a rare congenital cardiac anomaly and is mainly corrected through conventional surgery through sternotomy. We described our successful novel surgical technique of totally robotic correction of CTS in one case of CTS with concomitant repair of atrial septal defect using da Vinci SI Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA USA) with excellent surgical outcome. We conclude that robotic correction of CTS is a feasible and safe alternative to conventional surgical technique.

Right ventricular outflow tract (RVOT) obstruction is among the commonest congenital heart defects in the grown-up, and pulmonary stenosis is the dominant subtype. We described our successful novel surgical technique of totally robotic antegrade RVOT repair in two cases of pulmonary stenosis with concomitant repair of atrial septal defect using da Vinci SI Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA USA) with excellent surgical outcome. We conclude that robotic antegrade repair of the valvular and subvalvular subset of RVOT obstruction is feasible in adults.

Objective: This study aimed to investigate whether intra-myocardial injection of autologous bone marrow mononuclear cells (aBMMNCs) into peri-scarred myocardium during coronary artery bypass grafting (CABG) improved the long-term outcome compared with CABG alone.Methods: From April 2011 to December 2012, 33 patients with chronic ischemic heart failure were randomly assigned to undergo CABG (control group) or CABG combined with intra-myocardial injection of aBMMNCs (treatment group). The primary endpoints of the study were the changes of left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV) from baseline to six-month and two-year follow-up, respectively. The secondary endpoints were the changes of III and IV NYHA classification, 6-minute walk test, B-type natriuretic peptide (BNP) from baseline to follow-up, and major adverse cardiovascular events (MACES) during the follow-up.Results: No patient died and no severe surgical complication occurred perioperatively in either group. The mean number of transplanted aBMMNCs was 98.5 ± 48.3×106 per patient. The follow-up was completed at six months and 24 months postoperatively. No major transplant-related adverse events were detected during the study. The patients in the treatment group had more significant improvement in LVEF than in the control group at six-month follow-up (8.17% versus 4.71%, P = .020), but this benefit was not found at 24-month follow-up (7.44% versus 5.69%, P = .419). There was no significant difference in changes of LVEDV, LVESV, III and IV NYHA classification, 6-minute walk distance, BNP, and MACES between the two groups all through the study. Conclusion: Intra-myocardial injection of aBMMNC transplantation on arrested heart during CABG is a safe procedure based on a longer period observation. The patients with chronic ischemic heart failure can benefit from aBMMNCs transplantation in the short-term (6 months) demonstrated by improved global LVEF compared with the control group; however, this additional benefit dimed with time as showed by 24-month clinical and echocardiographic follow-up results.

Background: The impact of the grafting techniques (individual or sequential grafts) on the graft patency of off-pump coronary artery bypass grafting (OPCAB) has not been reported. The mid-term patency rates for individual and sequential saphenous vein grafts (SVGs) as coronary bypass conduits of OPCAB were compared. Methods: A total of 714 distal coronary anastomoses on 448 SVGs were assessed using a 64-multislice computed tomography in 398 patients at an average of 26.4 ± 23.6 months (three months to five years) after an OPCAB procedure. The blood flow of grafts in the proximal segment of individual and sequential SVGs was also compared. Results: The overall patency of sequential SVGs (95.9%) was significantly superior to individual ones (90.6%, p = 0.022). The anastomoses on the sequential conduits had better patency (95.1% vs. 90.1%, p = 0.013). The patency of side-to-side anastomoses (97%) was better than that of end-to-side anastomoses (93.1%) and also better than that of the individual end-to-side anastomoses (90.1%, p = 0.002, p = 0.041). No significant difference was observed between the two approaches in regard to the three major coronary systems; however, anastomoses on sequential grafts had superior patency to those on individual grafts in the right coronary system (p = 0.008). The blood flows of double and triple sequential SVGs were significantly higher than those of individual ones (p < 0.001, p = 0.048, respectively). Conclusions: The mid-term patency of a sequential SVG conduit after OPCAB is excellent and generally superior to that of an individual one. (J Card Surg 2010;25:633-637)

Objective This study is to discuss a surgical approach for ideal and safe resection of atrial myxoma using the da Vinci S Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif). Methods Nineteen consecutive patients underwent resection of atrial myxomas with the da Vinci S Surgical System. Mean age of the patients was 46 ± 16 years. Mean tumor size was 45 × 5.5 cm. Fifteen tumors were in the left atrium, of which 11 tumors arose from the interatrial septum, 2 from the posterocaudal wall, 1 from the root of the anterior leaflet of the mitral valve, and 1 from the left atrial roof. In 13 patients, exploration was conducted through a left atriotomy anterior to the pulmonary veins and excision was achieved by dissecting a plane through the atrial muscle at the point of attachment. In the first 2 patients, exploration and excision were conducted through an oblique right atriotomy. Four tumors were in right atrium, all of which were resected from the beating heart. The da Vinci instrument arms were inserted through three 1-cm trocar incisions in the right side of the chest. Via 4 port incisions and a 1.5-cm working port, all the procedures were completed with a 30° angled endoscope facing upward with the da Vinci S robot. Results Resection was successful in all patients. There were no operative deaths, strokes, or other complications. All the patients were discharged. No recurrences of tumor or septal leakage were found in the complete 1- to 18-month follow-up. Conclusions The excision of atrial myxomas with the da Vinci S Surgical System is feasible, efficacious, and safe. Surgical results are excellent.

Objective To evaluate the effect of a new ultrafiltration technique - subzero-balanced ultrafiltration technique - on early postoperative outcomes of adult patients undergoing cardiac operations with cardiopulmonary bypass. Methods A total of 120 patients who required cardiopulmonary bypass for cardiac surgery were randomized into two groups, 60 in each group. Patients in the treatment group received subzero-balanced ultrafiltration during cardiopulmonary bypass, while patients in the control group received routine cardiopulmonary bypass. Postoperative outcomes, including hospital mortality and morbidity of the two groups, were analyzed. Results Hospital mortality was 0% (0 of 60) in the treatment group versus 1.8% (1 of 60) in the control group (P=1.000). Total hospital complications was lower in the treated patients (11 of 60 [18.3%] versus 22 of 60 [36.7%], P=0.025). Duration of intubation time was shorter and transfusion volume within 24 hours postoperatively was less in patients having received subzero-balanced ultrafiltration during cardiopulmonary bypass (14.35 + or - 1.66 versus 18.64 + or - 1.57 h, P=0.036 and 1.54 + or - 1.56 versus 3.64 + or - 2.67 U/patient, P=0.032). Length of stay on the intensive care unit, duration of hospital stay, need for infusion of inotropic agent and drainage volumes within 24 h postoperatively between the two groups were comparable. Conclusions Subzero-balanced ultrafiltration during cardiopulmonary bypass can effectively decrease the patients' hospital morbidity and the volume of blood transfusion: it also may promote early postoperative recovery of patients. Routine application of subzero-balanced ultrafiltration during adult cardiac operations should not be necessary, but the technique should be compared to other techniques, e.g. MUF, in further studies.

Background Atrioventricular septal defect (AVSD) accounts for up to 3 % of congenital cardiac defects, which is routinely repaired via median sternotomy. Minimally invasive approach such as endoscopic or robotic assisted repair for AVSD has not been reported in the literature. With the experience with robotic mitral valve surgery and congenital defect repair, we initiated robotic AVSD repair in adults. Case Presentation In this report, we presented three cases of successful repair of partial and intermediate AVSD by using da Vinci SI surgical system (Intuitive Surgical, Inc., Sunnyvale, CA). Conclusions Totally robotic AVSD repair via right atriotomy could be safely performed in adults and it may provide superior cosmesis with the comparable surgical outcome of the repair via sternotomy.

Robotically assisted cardiac surgery is an alternative to conventional, open-chest surgery. Although studies have been done on the clinical effect, morbidity, and mortality of robotically assisted atrial myxoma excision, few have addressed surgical outcomes, such as pain, quality of life (QOL), and length of sick leave from work. In this study, our aim was to evaluate these clinical variables among patients after they undergo robotically assisted atrial myxoma excision surgery.Between January 2007 and January 2013, a total of 93 patients underwent either conventional sternotomy or robotically assisted atrial myxoma excision in our unit. The 36-item Medical Outcomes Study Short Form Survey was used to assess the clinical outcomes in these patients postoperatively, at day 30 and 6 months.The QOL scores for 7 of 8 variables in the robotically assisted group were significantly higher than those in the conventional group at postoperative day 30 (P.05). The degree of pain and its influence on work or life was lower in the robotically assisted group (P.05), and these patients returned to work after 0.9 ± 0.1 months, whereas those in the conventional group needed a sick leave of 3.3 ± 0.4 months.The level of restoration of normal QOL within 30 days after atrial myxoma surgery is excellent with the robotically assisted approach, which may enable early return to employment and satisfactory recovery.

Objective Recent advances in robotic instrumentation have facilitated totally endoscopic intracardiac procedures. However, totally endoscopic robotic ventricular septal defect (VSD) repair has not been reported in the literatures to our knowledge. We report our first three cases of closed chest VSD repair using da Vinci S Surgical System. Methods Three female patients underwent totally endoscopic robotic VSD repair. Echocardiography demonstrated that the perimembranous VSD sizes in three patients were 6, 8, and 8 mm, respectively, and a patent foramen ovale in one patient. Results All the VSD repair and right atrial closure were completed with the da Vinci robot. Mean cardiopulmonary bypass and mean cross-clamp times were 70 and 22 minutes, respectively. No blood transfusions were received. Postoperative transesophagel echocardiogram (TEE) demonstrated intact ventricular septum. The mean hospital stay was 5 days. The patients returned to normal function without any complications. Conclusions With a limited number of cases, the study showed that totally endoscopic robotic VSD repair in adult patients is feasible and safe.

Conventional cardiac surgery is performed via median sternotomy and central cardiopulmonary bypass (CPB) is performed through cannulation on ascending aorta and superior vena cava and inferior vena cava. Robotic surgical technology has provided port-access which has made peripheral CPB endoaortic balloon occluders possible. Establishment of peripheral CPB has been an important step for robotic cardiac surgery. The standard procedures of peripheral CPB establishment include right internal jugular cannulation and femoral artery and vein cannulation. This chapter describes the peripheral CPB technique which has been used routinely for totally robotic cardiac surgery using da Vinci Surgical System at the Chinese PLA General Hospital.

Background: The purpose of this study was to summarize our experience of extended ventricular septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM).Methods: Thirty-eight patients (26 men, 12 women) with HOCM underwent extended ventricular septal myectomy. The mean age was 36.3 years (range, 18-64 years). Diagnosis was made by echocardiography. The mean (mean � SE) systolic gradient between the left ventricle (LV) and the aorta was 89.3 � 31.1 mm Hg (range, 50-184 mm Hg) according to echocardiographic assessments before the operations. Moderate or severe systolic anterior motion (SAM) of the anterior leaflet of the mitral valve was found in 38 cases, and mitral regurgitation was present in 29 cases. Extended ventricular septal myectomy was performed in all 38 cases. The results of the surgical procedures were evaluated intraoperatively with transesophageal echocardiography (TEE) and with transthoracic echocardiography (TTE) at 1 to 2 weeks after the operation. All patients were followed up with TTE after their operation.Results: All patients were discharged without complications. The TEE evaluations showed that the mean systolic gradient between the LV and the aorta decreased from 94.8 � 35.6 mm Hg preoperatively to 13.6 � 10.8 mm Hg postoperatively (P = .0000) and that the mean thickness of the ventricular septum decreased from 28.3 � 7.9 mm to 11.8 � 3.2 mm (P = .0000). Mitral regurgitation and SAM were significantly reduced or eliminated. During the follow-up, all patients promptly became completely asymptomatic or complained of mild effort dyspnea only, and syncope was abolished. TTE examinations showed that the postoperative pressure gradient either remained the same or diminished.Conclusions: Extended ventricular septal myectomy is mostly an effective method for patients with HOCM, and good surgical exposure and thorough excision of the hypertrophic septum are of paramount importance for a successful surgery.

Inflammatory myofibroblastic tumor is currently considered to be a low-grade neoplasm, and it rarely involves the heart. We reported a rare case of a 59-year-old female who received cardiac surgery for complete resection of inflammatory myofibroblastic tumor in the left atrium. Five months after surgery, the patient presented with acute cardiogenic pulmonary edema and subsequent sudden death due to a left atrial tumor which protruded into the left ventricle through mitral annulus during diastole. The recurrence of inflammatory myofibroblastic tumor in the left atrium was strongly suggested clinically.

Objective We have previously reported total endoscopic ventricular septal defect repair in the adult using the da Vinci S Surgical System. The optimal results encouraged us to extend the use of this technology to more complicated patients with ventricular septal defect. Methods From January 2009 to July 2010, 20 patients underwent total endoscopic robotic ventricular septal defect repair. The average patient age was 29.0 ± 9.5 years (range, 16–45). Of the 20 patients, 9 were female and 11 were male. The echocardiogram demonstrated that the average diameter of the ventricular septal defect was 6.1 ± 2.8 mm (range, 2–15), and 4 patients had concomitant patent foramen ovale. Ventricular septal defect closure was directly secured with interrupted mattress sutures in 14 patients and patched in 6 patients. All the procedures were completed using the da Vinci robot by way of 3 port incisions and a 2.0- to 2.5-cm working port in the right side of the chest. Results All patients were operated on successfully. The mean cardiopulmonary bypass and mean crossclamp time was 94.3 ± 26.3 minutes (range, 70–140) and 39.1 ± 12.9 minutes (range, 22–75), respectively. The mean operation time was 225.0 ± 34.8 minutes (range, 180–300). The postoperative transesophageal echocardiogram demonstrated an intact ventricular septum. No residual left-to-right shunting and no permanently complete atrioventricular dissociation was found postoperatively. The mean hospital stay was 5 days. No residual shunt was found during a mean follow-up of 7 months (range, 1–22). The patients returned to normal function within 1 week without any complications. Conclusions Total endoscopic robotic ventricular septal defect repair in adult patients is feasible, safe, and efficacious.

This article aims to summarize the experience of 700 cases of robotic cardiac surgery with 7-year follow-up results revealed. A total of 700 patients underwent robotic cardiac surgery using da Vinci Surgical System from January 2007 to May 2014 in PLA General Hospital. There were 429 male and 271

Objective Despite the early introduction of totally endoscopic coronary artery bypass on the beating heart, only a limited number of cases have been performed. The limiting factor has been the concern about safety and graft patency of the anastomosis. This study describes our experience with totally endoscopic coronary artery bypass on the beating heart with robotic assistance and its early and midterm results. Methods In 365 cases of robotic cardiac operations, 162 patients underwent robotic coronary artery bypass grafting on the beating heart, of whom 60 patients (46 male, 14 female) underwent totally endoscopic coronary artery bypass on the beating heart. The patients' mean age was 56.97 ± 9.7 years (33–77 years). Left internal thoracic artery to left anterior descending anastomosis was performed using the U-Clip device. Results We completed 58 totally endoscopic coronary artery bypass procedures, in which 16 patients received hybrid procedures. Two patients had conversions to a minithoracotomy. The average left internal thoracic artery harvesting and anastomosis times were 31.3 ± 10.5 (18∼55) minutes and 11.3 ± 4.7 (5∼21) minutes, respectively. The mean operating room and operation times were 336.1 ± 58.5 (210∼580) minutes and 264.8 ± 65.6 (150∼420) minutes, respectively. The drainage was 164.9 ± 83.2 (70∼450) mL. Before discharge, 50 patients underwent angiography and 8 patients underwent computed tomography angiography, and the study showed that graft patency was 100%. Unexpectedly, the left internal thoracic artery graft developed a collateral branch in 2 patients. After discharge, all patients were followed up by computed tomography angiography. The average follow-up time was 12.67 ± 9.43 (1–40) months. One patient had gastric bleeding after surgery. Conclusions Totally endoscopic coronary artery bypass on the beating heart is a safe procedure in selected patients and produces excellent early and midterm patency of anastomosis.

Background: Atrial septal defect (ASD) repairs have successfully been performed on the arrested heart with the da Vinci S Surgical System (Intuitive Surgical). This study assessed the feasibility, safety, and efficacy of the use of the da Vinci S Surgical System for on-pump ASD repairs on the beating heart without cross-clamping the aorta.Methods: This prospective study included 24 consecutive patients who underwent ASD repair surgery between June 2008 and June 2009. All of the procedures were completed with the da Vinci S robot via 3 port incisions in the right chest and a 1.5-cm working port. The operations were carried out on the beating heart with mild hypothermic cardiopulmonary bypass (CPB) without cross-clamping the aorta. Venting the heart from the working port provided adequate visualization of the operative field.Results: All patients underwent complete repairs. Fourteen patients underwent ASD closure with a fresh autogenous pericardial patch, and 10 patients underwent direct ASD closure. Concomitant surgery was required in 4 patients. The mean (±SEM) CPB time was 65.6 ± 17.7 minutes, and the mean operative time was 98.5 ± 19.3 minutes. No patient required transfusion of red blood cells. The length of patient stay in the intensive care unit was 0.5 to 1.0 days. The length of hospital stay was 4 to 5 days. Follow-up transthoracic echocardiography evaluations showed no residual atrial septal leakage. There were no operative deaths, strokes, or other complications. All of the patients were discharged.Conclusions: We have shown that use of the da Vinci S Surgical System to perform on-pump ASD repairs on the beating heart without cross-clamping the aorta is feasible, safe, and effective.

Objectives Evaluate the feasibility and safety of two stop hybrid in the treatment of multivessel lesion in patients with acute coronary syndrome (ACS) in aging. Methods Two stop hybrid was adapted to treat consecutive aging patients of ACS with multivessel lesion selected by following criteria: 1. Left anterior ascending artery (LAD) was totally occluded in more than 3 months and three was at least one lesion with more than 80% stenosis in left circus flexes branch (LCX) or right coronary artery (RCA). 2. Coronary artery bypass graft was not contraindicated. 3. Informed consent was written to obtain two stop hybrid in following sequence: the patient was received micro port robot LIMA-LAD bypass at first in surgery and then transferred to cardiology in 2 weeks to complete sirolimus eluting stent implantation in LCX or RCA. Results Five patients (male 4, 67.52±4.16 years) were enrolled in the study. Their five LADs were occluded in 15.28±4.32 months. Three patients had 5 lesions in LCX and two had 4 lesions in RCA. Diabetes, hypertension and hyperlipidaemia were complicated in 4, 3 and 5 cases respectively. Three were no histories of myocardial infarction and stroke. Left ventricular ejection fraction was 57.34±6.12%. Three were no death or cardiac events in 2 weeks9 bridge period between surgery and cardiology. Micro port robot LIMA-LAD bypass were success in all five patients with patent bypass confirmed by angiography during stent implantation. Sirolimus eluting stents were implanted successfully in total 9 lesions of LCX and RCA. There were no death or cardiac events during the follow-up of 18.73±5.94 months. Conclusions Two stop hybrid is feasible and safe in selected aging patient of ACS with multivessel lesion. Large sample trial is needed to confirm long-term effect.