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Hypertrophic obstructive cardiomyopathy requires surgical myectomy when heart failure symptoms persist despite best medical therapy. Minimally invasively myectomy with robotic surgery can be performed in experienced centers allowing for surgical correction of accompanying mitral valve pathologies. The extent of myectomy is important to relieve left ventricular outflow tract obstruction while care should be taken to prevent iatrogenic ventricular septal defects or heart blocks caused by excessive removal of septal tissue. We report the use of intracardiac ultrasound during robotic surgery to intraoperatively assess the myocardium before and after myectomy to increase the safety of this procedure. Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic myocardial disease characterized by thickened myocardium and obstruction of the left ventricular outflow tract (LVOT). 1 Patients with symptoms of heart failure resistant to drug treatment are candidates for surgical septal myectomy. Conventionally performed through a midline sternotomy, septal myectomy can be carried out via transapical, transaortic, or transmitral approaches. The transmitral approach allows surgical treatment of the concomitant mitral valve pathology through a left atriotomy. Robotic septal myectomy can be performed in experienced centers with results comparable to the classical sternotomy approach with the added benefits of minimally invasive surgery. 2 Excessive removal of septal tissue can result in a heart block or a ventricular septal defect while an inadequate myectomy can leave a high gradient in the LVOT. Intracardiac ultrasound can assist the surgeon in performing a safe and adequate myectomy. We describe our technique for intracardiac ultrasound guided robotic septal myectomy in a patient with HOCM and infective endocarditis.

Background: In this study, we aimed to evaluate early and longterm outcomes of both isolated or concomitant coronary artery bypass grafting with the endoscopic vein harvesting technique. Methods: Between November 2012 and May 2017, a total of 324 patients (259 males, 65 females; mean age: 63.2±9.8 years; range, 36 to 91 years) who underwent coronary artery bypass grafting, with or without concomitant procedures, using the endoscopic vein harvesting technique were retrospectively analyzed. Early postoperative outcomes and long-term follow-up data of the patients, such as cardiovascular or cerebral events, cardiac reinterventions, and the images of coronary angiography were recorded. Results: Median logistic EuroSCORE and in hospital mortality was 3.99 (0.8-81) vs. 0 .9% f or i solated c oronary surgery and 13.34 (1.5-76.4) vs. 1.5% for concomitant procedures. The long-term data could be obtained in 288 patients with a median of 59.6 (7-90) months of follow-up. During this period, 22 (7.6%) patients underwent coronary angiography for control or treatment, 12 (4.2%) patients needed revascularization, and none of the patients underwent redo coronary surgery. Conclusion: Our study results suggest that the endoscopic vein harvesting technique during coronary artery bypass grafting is safe in experienced hands.

INTRODUCTION Robotic cardiac surgery offers mitigated risks for obese patients requiring mitral valve surgery. We aimed to study the safety of robotic mitral surgery in the obese patient population by analyzing the outcomes of mitral surgery patients in our center for robotic cardiac surgery. METHOD This study retrospectively included 123 consecutive patients who underwent robotic mitral valve operations in a single center for robotic cardiac surgery. Patients with body mass index (BMI) ≥ 30 were compared against patients with BMI

Background and Aim Attempting to place an aortic cross-clamp may complicate surgery and postoperative outcomes in patients who have mediastinal adhesions or in those with extensive aortic calcification. Although right-sided cardiac surgery via thoracotomy is not a new technique in these patients, robotic-assisted intracardiac repair without cross-clamping was not reported in a large group of patients previously. In this study, the safety of robotic-assisted cardiac surgery without aortic cross-clamping was examined. Methods From January 2010 to March 2020, 304 patients underwent robotic-assisted cardiac surgery in our center and in 25 of these patients (8.2\%) with a mean age of 65.5 +/- 20 years myocardial protection was succeeded with moderate hypothermic ventricular fibrillatory arrest. Severe pericardial adhesions or existence of highly calcified ascending aorta were the indications for fibrillatory arrest during robotic assistant surgery. Results Most patients were in New York Heart Association Class >= II (88.0\%) and the mean logistic Euroscore value was 18.5 +/- 22.3. The type of operations were mitral/tricuspid valve repair/replacement, cryoablation, atrial septal defect closure, and pericardiectomy. Cardiopulmonary bypass times were 141.5 +/- 47 (minimum 77-maximum 252) min. There was no case of conversion to open thoracotomy or sternotomy. Hemiparesis was observed in one patient. Two patients with 78.2 and 81.9 Euroscore values had mesenteric ischemia and multiorgan failure, respectively, and died at postoperative period. Conclusions Robotic-assisted cardiac surgery without cross-clamping may provide reasonable outcomes in patients with severe aortic calcification or mediastinal adhesions undergoing intracardiac repair. These acceptable outcomes may encourage surgeons to perform this approach in appropriate group of patients.

Introduction Robotic valve surgery utilizes the femoral vessels to set up cardiopulmonary bypass (CPB) which translates to groin wound and lower extremity vascular complications. A less invasive technique is a totally percutaneous bypass using vascular closure devices (VCDs) with concerns for lower limb ischemia and arterial stenosis. Since April 2018, we have adopted the standard use of total percutaneous CPB in our robotic mitral cases. We report our institutional results with this technique. Methods All consecutive patients who underwent robotic mitral valve surgery between April 2018 and December 2020 in our institution were included in our study. Hospital database data on demographics, operative variables, and surgical outcomes were recorded and analyzed. Results Robotic mitral valve surgeries were performed on 32 consecutive patients (mean age 57.2 ± 14.8) between April 2018 and December 2020. None of our patients developed an infection at any site. Seroma, hematoma, or pseudoaneurysm were not observed at puncture sites. Surgical repair of the femoral vessels or an additional VCD was not necessary for any of our patients. Patients were followed up for a mean duration of 23.5 months. Our patients did not present with a late wound infection, a seroma, or a pseudoaneurysm, nor had complaints of limb ischemia or claudication. Conclusion Total percutaneous bypass is the least invasive method of establishing extracorporeal circulation for cardiac surgery and can be performed with excellent results. The benefits of robotic surgery can be expanded with better results in groin cannulation by the adoption of total percutaneous CPB.

Background: Red blood cell (RBC) transfusion increases morbidity and mortality after cardiac surgery. Despite the use of patient blood management methods, blood transfusions may still be needed in cardiac surgery. This study aims to determine the risk factors for blood transfusions in isolated coronary bypass graft surgery with the use of a restrictive transfusion strategy along with individualized patient blood management. Methods: A total of 198 consecutive patients (28 females, 170 males; age range 38–87) who underwent isolated CABG surgery in single private hospital using a restrictive transfusion strategy between April 2015 and October 2020 were included in the study. Patients were divided into two groups: with RBC transfusion and without RBC transfusion. Preoperative, intraoperative, and postoperative values were compared between groups. The risk factors for transfusion and transfusion probability were analyzed. Results: Preoperative hematocrit level and female gender (OR: 0.752; 95% CI 0.639–0.884; p = 0.001; OR: 7.874; 95% CI 1.678–36.950; p = 0.009, respectively) were the statistically significant independent risk factors for red blood cell transfusion. In female patients, the RBC transfusion probability was 61.08% when the preoperative hematocrit was 30%. The intensive care unit and hospital stay were longer in the blood transfusion group. Conclusions: The risk factors for RBC transfusion were preoperative anemia and female gender in isolated CABG surgery with restrictive blood transfusion strategies. Keywords: anemia, blood transfusion, coronary artery bypass, patient blood management, restrictive blood transfusion

Background The feasibility, safety and advantages of minimally invasive or robotic repair of atrial septal defect (ASD) in adults were reported previously. However, there is limited data for the application of these systems in paediatric patients. Although current robotic systems still have large instruments for surgical repair in children, some appropriate patients may benefit from this technology. Method A 6-year-old child with ASD underwent robotic assistant repair via Da-Vinci Robotic Systems. Venous cannulation was achieved by internal jugular and femoral veins (10F-14F) and arterial cannulation was performed via femoral artery under transesophageal echocardiography (TEE) guidance (10F). A 3 cm incision was made in the right fourth intercostal space, used for working and the camera port in the same time. The ports were placed considering not to damage the potential developing breast tissue. After the port implantation (8F) and cardiac arrest, the ASD repair was completed with primary closure technique. Result The perioperative period was uneventful and the patient was discharged from hospital 5 days after surgery. Conclusion ASD closure with robotic assistant was achieved in a large enough sized paediatric patient. With the development of thinner and shorter robotic arms, it will be possible to use robotic assistance more common during the repair of congenital heart diseases.

Background and Aim: Attempting to place an aortic cross-clamp may complicate surgery and post operative outcomes in patients who have mediastinal adhesions or in those with extensive aortic calcification. Although right sided cardiac surgery via thoracotomy is not a new technique in these patients, robotic-assisted intracardiac repair without cross-clamping was not reported in a large group of patients previously. In this study, the safety of robotic-assisted cardiac surgery without aortic cross-clamping was examined. Methods: From January 2010 to March 2020, 304 patients underwent robotic-assisted cardiac surgery in our center and in 25 of these patients (8.2%) with a mean age of 65.5±20 years myocardial protection was succeeded with moderate hypothermic ventricular fibrillatory arrest. Severe pericardial adhesions or existence of highly calcified ascending aorta were the indications for fibrillatory arrest during robotic assistant surgery. Results: Most patients were in NYHA class ≥II (88.0%) and mean logistic Euroscore value was 18.5±22.3. The type of the operations were mitral/tricuspid valve repair/replacement, Cryoablation, ASD closure and pericardiectomy. CPB times were 141.5±47 (min 77- max 252) minutes. There was no case of conversion to open thoracotomy or sternotomy. Hemiparesis was observed in one patient. Two patients with 78.2 and 81.9 Euroscore values had mesenteric ischemia and multi-organ failure, respectively, and died at postoperative period. Conclusions: Robotic-assisted cardiac surgery without cross-clamping may provide reasonable outcomes in patients with severe aortic calcification or mediastinal adhesions undergoing intracardiac repair. These acceptable outcomes may encourage surgeons to perform this approach in appropriate group of patients.

Although thoracic endovascular aortic repair (TEVAR) is associated with reduced mortality and shorter hospital stay compared to open surgery, the decrease in stroke risk did not reach the desired rates. Aortic arch manipulation is one of the main concerns leading to stroke during TEVAR. Here, we describe a new technique called “Acibadem Technique” to avoid arch and ascending aorta manipulation with catheterization of left subclavian artery for endovascular distal descending aortic repair.

Hybrid treatment of aortic arch encompasses a combination of endovascular stenting with surgical revascularization of supra-aortic branches. Herein, we report a 53-year-old male case of type B aortic dissection with retrograde extension and anomalous aortic arch. The patient was successfully treated by hybrid treatment using bilateral carotico-subclavian bypass grafting and endovascular stent grafting.

Objective We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease. Methods From March 2010 to June 2013, a total of 63 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical systems (Intuitive Surgical, Inc, Sunnyvale, CA USA). Eighteen of the patients (28.5%) underwent robotic mitral valve replacement. Rheumatic disease was the underlying pathology in all patients. The mean (SD) follow-up period was 18 (10) months. Results The mean (SD) age and EuroSCORE of the patients were 51.2 (11) years and 4.1% (4%), respectively. Seven patients (38.8%) had an additional cardiac procedure. No operative and hospital mortality were observed. The mean (SD) cross-clamp time and cardiopulmonary bypass time were 116 (30) and 178 (54) minutes, the mean (SD) drainage was 430 (350) mL, the mean intubation time was 9.4 (7) hours, the rate of patients extubated within 6 hours or less was 94.4%, and the mean (SD) intensive care unit stay time was 30 (12) hours. Sixteen of the patients (88.8%) were discharged from the intensive care unit within the first 24 hours postoperatively. During the intensive care unit stay, one patient (5.5%) needed inotropic support. There was one early reoperation for bleeding (5.5%), one (5.5%) intensive care unit readmission, and one (5.5%) hospital readmission observed. During the midterm follow-up, there was no mortality and no need for reoperation or reintervention. Conclusions Robotic mitral valve replacement for severe rheumatic mitral disease is technically feasible. Early results are encouraging. Patient selection criteria for robotic mitral valve surgery may be expanded to include valve replacements.

Gebode defect, that can accurately be treated surgical repair, is defined as a true communication between left ventricle and right atrium. A 74-year-old woman with a worsening history of ortophnea and peripheral edema was hospitalised. A communication between right atrium and left ventricle was diagnosed using transeusophageal echocardiography. The defect was repaired and mitral valve was replaced with a biologic valve. It would be beter to tailor surgical strategy for each case with atrioventricular canal defect after preoperative transeusophageal echocardiography and peroperative direct sight.

Eden Prairie, MN, USA) and the CFV was cannulated with a 24-Fr venous cannula (Medtronic Bio-Medicus, Eden Prairie, MN, USA) using the Seldinger technique and TEE guidance. The tip of the venous cannula was placed 1 cm superior to the cavoatrial junction. A 3 cm incision was made between the anterior axillary line and midclavicular line at the fourth intercostal space. The right lung was deflated and a small soft tissue retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was placed. The camera port was inserted through this soft tissue retractor. The right arm port was placed one or two intercostal spaces inferior to the soft tissue retractor, and the left arm port was placed one intercostal space superiorly. The sites for the two arms were placed in a line perpendicular to the incision at the fourth intercostal space. The left atrial retractor port was placed 3 cm medial to the soft tissue retractor in the same intercostal space. The robotic arms were connected to the ports. Carbon dioxide insufflation was applied at a pressure of 6 mmHg and a flow rate of 6 L/min. After the institution of cardiopulmonary bypass, the pericardium was opened with an incision starting 2 cm anterior and parallel to the phrenic nerve. Two pericardial retraction sutures were passed through the lateral chest wall and fixed externally. The transverse sinus of pericardium was controlled with the tip of a suction device for detection of any possible adhesions at the posterior wall of the ascending aorta. A transthoracic Chitwood aortic clamp was inserted through the chest wall in the direction of the transverse sinus. The inferior jaw of the clamp was placed in the transverse sinus. A temporary needle for cardioplegia was placed in the ascending aorta through the soft tissue retractor. The ascending aorta was clamped with the transthoracic clamp.

Amac: Bu calismada kardiopulmoner baypas (KPB) sirasinda venoarteriyel karbondioksit farki (Dv-a PCO2) ve laktat arasindaki muhtemel iliskisi arastirildi. Ca­lis­ma­pla­ni:­Hastanemiz etik kurulu onayi ve hasta onamlari alinan elektif izole koroner arter baypas greft (KABG) cerrahisi yapilacak 60 ardisik hasta (35 erkek, 53 kadin; ort. yas 64 yil; dagilim 38-78 yil) calismaya alindi. Tum hastalar ayni anestezi ve cerrahi ekip tarafindan izlendi. Kardiopulmoner baypas suresince doku perfuzyonun yeterliligi venoarteriyel parsiyel karbondioksit farki, laktat duzeyi, arteriyel ve venoz kan gazi olcumu, idrar cikis hizi ve hemodinamik parametrelerin analizi ile degerlendirildi. Olcumler kardiopulmoner baypas oncesi (T1), KPB baslangicinda 36 oC’de (T2), hipotermide 32 oC’de (T3) ve yeniden isinmanin sonunda 37 oC’de (T4) olmak uzere dort periyotta yapildi. Doku perfuzyon parametreleri arasindaki iliski, Pearson korelasyon analizi ile degerlendirildi. Bul gu lar: Kardiopulmoner baypasin T2 ile T4 periyotlari arasinda doku perfuzyon parametrelerinden Dv-aPCO2 ile arteriyel laktat duzeyi (r=0.55, p=0.042) ve Dv-aPCO2 ile venoz laktat (r=0.54, p=0.046) arasinda anlamli iliski vardi. T3-T4 periyotlari arasinda da Dv-aPCO2 ile arteriyel base excess (BE) (r=-064, p=0.013,), Dv-aPCO2 ile arteriyel HCO3 (r=-0.54, p=0.048) arasinda anlamli iliski vardi. So­nuc:­Calisma bulgularimiz, hipotermi doneminde, karbondioksit cozunurlugundeki degisiklige bagli olarak, KBP sirasinda venoarteriyel karbondioksit farkindaki (Dv-aPCO2) artisin yetersiz kan akimi ile ters orantili olmadigini ve hipotermi periyodu disindaki donemlerde, Dv-aPCO2 ile doku perfuzyon parametreleri arasinda anlamli bir iliskinin oldugunu gostermistir. Anah tar soz cuk ler: Kardiyopulmoner baypas; doku perfuzyonu; venoarteriyel karbondioksit farki. Background:­In this study, we aimed to investigate the possible relationship between the venoarterial gradient of carbon dioxide (Dv-a PCO2) and lactate during cardiopulmonary bypass (CPB). Methods: Sixty consecutive patients (35 males, 53 females; mean age 64 years; range 38 to 78 years) who were scheduled for elective isolated coronary artery bypass graft (CABG) surgery were included in the study after obtaining their informed consent and the approval of the ethics committee of the hospital. All patients were followed up by the same surgical and anesthesia team. The adequacy of tissue perfusion during CPB was evaluated by the venoarterial partial carbon dioxide gradient, lactate level, measurement of arterial and venous blood gas, urinary flow rate, and hemodynamic parameters. The measurements were performed in four periods: before CPB (T1), at the beginning of CPB (T2) at 36 oC and 32 oC of hypothermia (T3) and at the end of rewarming (T4) at 37 oC. The relationship between tissue perfusion parameters was assessed by Pearson’s correlation analysis. Results:­There was a significant correlation between Dv-aPCO2 and the venous lactate level (r=0.54, p=0.046) as well as between Dv-aPCO2 and the arterial lactate level (r=0.55, p=0.042) during the T2 and T4 periods of CPB. There was also a significant correlation between Dv-aPCO2 and arterial base excess (BE) (r=0.64, p=0.013) and between Dv-aPCO2 and arterial HCO3 (r=0.54, p=0.048) during the T3 and T4 periods. Conclusion:­Our study results suggest that in the hypothermia period, the increase in the venoarterial carbon dioxide gradient (Dv-aPCO2) is not inversely associated with insufficient blood flow during CPB and there was a significant correlation between Dv-aPCO2 and the tissue perfusion parameters during the periods other than hypothermia.

Robotik cerrahi, kalp cerrahisinin gelisiminde onemli bir adimdir. Bu yazida, ulkemizde 55 yasinda bir erkek olguya yapilan ilk robotik yardimli cift kapak girisimi sunuldu. Anah tar soz cuk ler: Minimal invaziv kalp cerrahisi; robotik cerrahi. Robotic surgery is an important step in the evolution of cardiac surgery. In this article, we report a 55-year-old male case who underwent first robotic-assisted double valve intervention in Turkey.

Robotic surgical techniques allow surgeons to perform mitral valve surgery. This procedure has gained acceptance, particularly for mitral valve repair in degenerative mitral disease. However, mitral repair may not always be possible, especially in severely calcified mitral valve of rheumatic origin. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair.

OBJECTIVE Use of the radial artery (RA) as a conduit in coronary artery bypass grafting (CABG) has become increasingly popular in recent years. The aim of this prospective randomized study is to determine how the endothelial wall and blood flow of RA are differently affected with the usages of ultrasonic scalpel and conventional electrocautery in addition to effects of hypothermia and storage solutions. Histopathologic study was achieved by electron microscope to evaluate endothelium of the grafts. METHODS Between 2008 and 2009, 182 patients with coronary artery diseases were operated for coronary artery revascularization. The radial arteries were harvested for 40 of these patients and divided into two groups depending on the use of the ultrasonic cautery (UC) (n=20) and the high-frequency electrocautery (EC) (n=20). Patients were divided into two subgroups according to the storage media of the graft. RA was preserved in situ at room temperature (Group 1) and normothermic organ bath (NOB) (Group 2). Harvesting time, use of hemostatic clips, frequency of spasm, in situ free flow, temperature and endothelial damage were compared between the two groups. Statistical analysis was performed using one-way ANOVA, Friedman and unpaired t tests. RESULTS In all groups, blood flows were significantly decreased as parallel to the local temperatures. Second and third phase flows were similar in group EC1 and UC1 (p>0.05). Free flow was increased in group UC+NOB when comparing with only EC group (60.4±9.83 ml/min and 40.8±7.50 ml/min, p

In non-addicted patients, several states such as alcoholism, previous valvular heart disease or prosthetic valve replacement, immunodeficiency states, prolonged intravenous hyperalimentation, permanent pacemakers, and some congenital heart diseases can provide the predisposing factors for tricuspid valve endocarditis. It is an extremely rare occurrence in patients with normal native cardiac valves. In this report, we present a case of a 67-year-old woman with tricuspid native valve endocarditis related to Candida parapsilosis which is a very rare cause of infective endocarditis and carries a high mortality risk. An operation was indicated for the patient due to persistent enlarging vegetation on tricuspid valve, severe tricuspid regurgitation, septic pulmonary emboli and finally uncompensated respiratory and heart failure. She underwent tricuspid valve replacement with bioprothesis three years ago and now she is in a satisfactory condition without any medical treatment.

Both genetic and environmental factors are involved in the development of coronary artery disease (CAD). The degree of contribution of each individual risk factor on CAD is unknown. The extent to which the familial occurrence of coronary heart disease is due to genetic mechanisms can be assessed in twins. In our opinion, due to the chance of mortality risk in monozygotic twin being about 20 times higher than for a representative individual in the overall population, and 3.2- to six-fold higher than for the dizygotic twin of a patient with myocardial infarction, aggressive cardiac evaluation is essential for the asymptomatic twin especially if symptomatic pair's lesion is critical. This report describes similar coronary angiographic findings of identical twins with different coronary risk factors. They both underwent coronary bypass revascularization and had similar uneventful postoperative follow-up.

The purpose of the present study was to investigate retrospectively which aortic clamping technique, the single clamp technique (SCT) or double clamping technique (DCT), is safer in terms of cerebral functions in patients who have undergone coronary bypass surgery. We evaluated 1100 patients who underwent coronary artery bypass graft surgery at our institute from 1998 to 2004. The two groups, SCT (n = 550, 50%) and DCT (n = 550, 50%), were comparable with respect to smoking, hypertension, hypercholesterolemia, diabetes mellitus, chronic obstructive pulmonary disease, peripheral arterial disease, history of neurological events, creatinine levels, and existence of a carotid lesion. No significant differences between the SCT and DCT groups were observed in terms of cardiac and cerebral complications perioperatively and postoperatively. Both single and double clamping techniques have advantages and disadvantages in patients undergoing coronary bypass surgery.

We describe a novel surgical technique for occlusion of the superior and inferior venae cavae which allows opening of the right atrium safely during robotic cardiac surgery.

Atrial septal defect (ASD) is one of the most common congenital cardiac diseases. This pathology can be treated with percutaneous devices. However, some of the ASDs are not suitable for device closure. Also, there may be device-related late complications of transcatheter ASD closure. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate. This study demonstrates the basic concepts and technique of robotic ASD closure.

In this report, not only our experience with laparoscopy-assisted robotic aortic thrombectomy and aortobiiliac bypass procedure was presented but also current status of vascular interventions via endoscopically was discussed.

PP-044 The aim of this study is to investigate the early and midterm results of valve sparing aortic root replacements. Between 1999 and 2013 a total of 7220 patients underwent cardiac operations, 26 of them (0.3%) were valve sparing aortic root replacements. The aortic pathology included either

PP-043 The beneficial effects of the calcium sensitizer levosimendan have previously been demonstrated in patients undergoing coronary surgery (CABG) with left ventricular dysfunction however there are still questions regarding optimal dosing and timing of therapy. The goal of this study was to

The relationship between epicardial adipose tissue (EAT) and coronary artery disease has been predominantly demonstrated in the last two decades. The aim of this study was to investigate the predictive value of EAT thickness on ST-segment resolution that reflects myocardial reperfusion in patients undergoing primary percutaneous coronary intervention (pPCI) for acute ST-segment elevation myocardial infarction (STEMI). The present study prospectively included 114 consecutive patients (mean age 54 ± 10 years, range 35-83, 15 women) with first acute STEMI who underwent successful pPCI. ST-segment resolution (ΔSTR)