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We introduce an intrapericardial control technique using a robotic approach in the surgical treatment of renal tumor with level IV inferior vena cava thrombus to decrease the severe complications associated with cardiopulmonary bypass and deep hypothermic circulatory arrest.Eight patients with level IV inferior vena cava thrombi not extending into the atrium underwent transabdominal-transdiaphragmatic robot-assisted inferior vena cava thrombectomy obviating cardiopulmonary bypass/deep hypothermic circulatory arrest (cardiopulmonary bypass-free group) by an expert team comprising urological, hepatobiliary, and cardiovascular surgeons. The central diaphragm tendon and pericardium were transabdominally dissected until the intrapericardial inferior vena cava were exposed and looped proximal to the cranial end of the thrombi under intraoperative ultrasound guidance. As controls, 14 patients who underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass (cardiopulmonary bypass group) and 25 patients who underwent open thrombectomy with cardiopulmonary bypass/deep hypothermic circulatory arrest (cardiopulmonary bypass/deep hypothermic circulatory arrest group) were included. Clinicopathological, operative, and survival outcomes were retrospectively analyzed.Eight robot-assisted inferior vena cava thrombectomies were successfully performed without cardiopulmonary bypass, with 1 open conversion. The median operation time and first porta hepatis occlusion time were shorter, and estimated blood loss was lower in the cardiopulmonary bypass-free group as compared to the cardiopulmonary bypass group (540 vs 586.5 minutes, 16.5 vs 38.5. minutes, and 2,050 vs 3,500 mL, respectively). Severe complications (level IV-V) were also lower in the cardiopulmonary bypass-free group than in cardiopulmonary bypass and cardiopulmonary bypass/deep hypothermic circulatory arrest groups (25% vs 50% vs 40%). Oncologic outcomes were comparable among the 3 groups in short-term follow-up.Pure transabdominal-transdiaphragmatic robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass/deep hypothermic circulatory arrest represents as an alternative minimally invasive approach for selected level IV inferior vena cava thrombi.

Vascular smooth muscle cells (VSMCs) phenotype switching is very important during the pathogenesis and progression of vascular diseases. However, it is not well understood how normal VSMCs maintain the differentiated state. The large-conductance CaWe assessed BKBK

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.

OBJECTIVE: To compare the mid- and long-term outcomes of patients receiving mitral valve replacement through robotically assisted and conventional median sternotomy approach. METHODS: The data of 47 patients who underwent da Vinci robotic mitral valve replacement in our hospital between January, 2007 and December, 2015 were collected retrospectively (robotic group). From a total of 286 patients undergoing mitral valve replacement through the median thoracotomy approach between March, 2002 and June, 2014, 47 patients were selected as the median sternotomy group for matching with the robotic group at a 1:1 ratio. The perioperative data and follow-up data of the patients were collected, and the quality of life (QOL) of the patients at 30 days and 6 months was evaluated using the Quality of Life Short Form Survey (SF-12). The time of returning to work postoperatively and the patients' satisfaction with the surgical incision were compared between the two groups. RESULTS: All the patients in both groups completed mitral valve replacement successfully, and no death occurred during the operation. In the robotic group, only one patient experienced postoperative complication (pleural effusion); in median sternotomy group, one patient received a secondary thoracotomy for management of bleeding resulting from excessive postoperative drainage, and one patient died of septic shock after the operation. The volume of postoperative drainage, postoperative monitoring time, ventilation time, and postoperative hospital stay were significantly smaller or shorter in the robotic group than in the thoracotomy group (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups. Assessment of the patients at 30 days after the operation showed a better quality of life in the robotic group, but the difference between the two groups tended to diminish at 6 months. The patients in the robotic group reported significantly better satisfaction with the incision than those in the thoracotomy group (P < 0.001). At 6 months after the operation, the patients in the robotic group showed significantly faster recovery of work and daily activities than those in the thoracotomy group. CONCLUSION: Robotically assisted mitral valve replacement is safe and reliable. Compared with the median sternotomy approach, the robotic approach is less invasive and promotes faster postoperative recovery of the patients, who have better satisfaction with the quality of life and wound recovery.

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.

The present study aimed to identify biomarkers for the clinical diagnosis of acute myocardial infarction (AMI) in a Chinese population using microarray data collected from the Gene Expression Omnibus database under accession number GSE97320. This included the peripheral blood samples of three patients with AMI and three controls. Differentially expressed genes (DEGs) were identified using the limma package and protein-protein interaction networks were constructed using data from the Search Tool for the Retrieval of Interacting Genes database, followed by module analysis to screen for hub genes. Functional enrichment analyses were performed using the Database for Annotation, Visualization and Integrated Discovery. The identified genes were verified by overlapping with the target genes of microRNAs (miRs) known to be associated with AMI, as well as the DEGs identified in other AMI datasets, including GSE24519, GSE34198 and GSE48060. As a result, 752 DEGs (449 upregulated and 303 downregulated) were identified in the GSE97320 dataset. The upregulated DEGs were predicted to participate in inflammatory pathways, including the toll-like receptor (TLR) signaling pathway, including ras-related C3 botulinum toxin substrate 1 (RAC1), TLR4, C-C motif chemokine receptor (CCR)1; cytokine-cytokine receptor interaction, including signal transducer and activator of transcription (STAT)3; chemokine signaling pathway, including CCR10; pathways associated with cancer, including colony stimulating factor 3 receptor (CSF3R); and leukocyte transendothelial migration, including matrix metallopeptidase 9 (MMP9). The downregulated DEGs were associated with the cell cycle, including alstrom syndrome protein 1 (ALMS1). These conclusions were made following functional analysis of the genes in the three identified modules. MMP9, TLR4, STAT3, CCR1 and ALMS1 were regulated by miR-21-5p, whereas RAC1 was regulated by miR-30c-5p. A comparison among the four datasets confirmed the roles of CSF3R and CCR10. HtrA serine peptidase 1 (HTRA1) was the only gene associated with both mortality and recurrence. In conclusion, inflammation-associated genes, including STAT3, CCR1, RAC1, MMP9, CCR10, CSF3R and HTRA1, as well as cell cycle-associated genes such as ALMS1, may be biomarkers for the diagnosis and prognosis of AMI in Chinese people.

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.

To assess the short-term outcomes of staged hybrid coronary revascularization performed using robotic-assisted off-pump coronary bypass grafting followed by percutaneous coronary intervention (PCI) in a non-left anterior descending (LAD) coronary artery lesion.From January, 2007 to May, 2013, 35 patients (32 male and 3 female patients, mean age 56.7 ± 9.6 years) underwent staged hybrid coronary revascularization. Ten patients had double-vessel and 25 patients had triple-vessel coronary diseases, and the lesions involved an average of 2.7 ± 0.5 coronary vessels. Coronary artery bypass grafting was completed in robotic-assisted left internal thoracic artery (ITA) harvesting and LITA to LAD bypass. Coronary angiography or 64-MSCT was performed to evaluate the patency of the ITA and stents at 6 months and at 1 to 5 years postoperatively. The patients were followed for major adverse cardiac events (MACE) including cardiac death, acute myocardial infarction and target lesion revascularization.Staged hybrid revascularization was completed successfully in all the patients without complications. The LITA to LAD anastomosis was completed in minimally invasive direct coronary bypass grafting (MIDCAB) or totally robotic coronary bypass grafting on beating heart (TECAB) with the assistance of da Vinci Surgical System. The mean artery graft flow was 36.0 ± 22.5 ml/min, and the graft had a 100% patency before discharge. A total of 49 stents were deployed in 35 patients within 2 weeks after robotic coronary bypass grafting, with a mean of 1.34 ± 0.6 stents per case (1 stent in 23 cases, 2 stents in 11 cases, and 3 stents in 1 case). The patients were followed up for 17.5 ± 11.6 months, and 1 patient had artery graft occlusion and another had in-stent occlusion at 6 months. All the other 33 patients had patent LITA-to-LAD anastomosis without angina or MACE.Staged hybrid revascularization strategy has acceptable angiographic patency results for both LITA-LAD grafts and PCI interventions.

To analysis the influence of surgical revascularization on different timing after ST-elevation myocardial infarction (STEMI) on patients with coronary artery disease and left ventricular dysfunction.Clinical data of 225 patients admitted from January 2003 to July 2012 with history of STEMI and left ventricular dysfunction (ejection faraction50%) who underwent isolated coronary artery bypass grafting was retrospectively reviewed. There were 186 male and 39 female patients. According to the timing of surgical revascularization after STEMI, the patients were divided into early revascularization group (ER group,21 days), mid-term revascularization group (MR group, 21 to 90 days) and late revascularization group (LR group,90 days). There were 20 male and 9 female patients in ER group with mean age of (63 ± 10) years, 48 male and 16 female in MR group with mean age of (63 ± 8) years, 118 male and 14 female in LR group with mean age of (62 ± 10) years, respectively. Thirty-day post-operative mortality and major complications were determined as the endpoints to evaluate the early results of operation.The 30-day post-operative mortality were 3.4%,0 and 2.3% among three groups respectively and there was no statistic difference between groups (χ(2) = 2.137, P = 0.330).Low cardiac output syndrome mortality were 13.8%, 3.1% and 2.3% among three groups respectively and there was statistic difference between groups (χ(2) = 8.344, P = 0.015). The ejection fractions was significantly improved in all the three groups from 42% ± 6%, 41% ± 6% and 42% ± 6% preoperatively to 46% ± 7%, 45% ± 10% and 45% ± 9% postoperatively (t = -3.378 to -2.339, all P0.05). The left ventricular end diastolic dimension were significantly reduced in MR group and LR group from (54 ± 6) mm and (55 ± 6) mm preoperatively to (47 ± 8) mm and (49 ± 9) mm postoperatively (t = 5.634, 5.885; P = 0.000). There was no significant change in ER group pre- and postoperatively ((51 ± 6) mm vs.(49 ± 7) mm, t = 1.524, P = 0.133).The patients with coronary artery disease and left ventricular dysfunction can benefit from surgical revascularization on different timing after STEMI, presenting as the reverse of left ventricle remodeling and the improvement of left ventricle function. The short-term results are mainly determined by the patients' condition, surgical technique and the level of perioperative management.It is recommended for this patient cohort to accept surgical revascularization three weeks after STEMI.

To evaluate the changes of circulating hematopoietic progenitor cells (cHPCs) in patients undergoing coronary artery bypass graft (CABG) surgery.Fifty-one patients scheduled to undergo elective CABG surgery were prospectively enrolled in this study. Blood samples were collected at baseline and at 1, 3, and 5 days after the surgery. CD34⁺ CD45dim, CD133⁺ CD45dim, and CD34⁺ CD133⁺ CD45dim cells were measured by flow cytometry. The functionality of the circulating progenitor cells were studied in vitro using clonogenic and migration assays.All the elective patients showed a significant postoperative increase of CD34⁺ CD45dim (1.51 ± 1.26 vs 2.02 ± 1.16, P=0.036) and CD133⁺ CD45dim cells (1.16 ± 0.85 vs 1.65 ± 0.99, P=0.008) irrespective of on-pump or off-pump CABG. The perioperative changes of the cHPCs was more significant in patients undergoing on-pump surgery than those having off-pump surgery.In patients undergoing elective cardiac surgery, cHPC level increased early after the surgery but recovers the normal level over time.

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.

To summarize the experience with emergency coronary artery bypass grafting (ECABG) for management of acute coronary syndrome and analyze the mid-term follow-up results.Forty-five ECABG surgeries were performed in 34 male and 11 female patients (aged 65.6∓5.8 years) for cardiogenic shock (5 cases), acute heart failure (6 cases) and refractory unstable angina (34 cases). Twenty patients received the operation within one week after acute myocardial infarction (AMI) and 18 were preoperatively supported by intra-aortic balloon pumping (IABP). All patients had triple-vessel disease and 15 had left main stenosis. Ten patients experienced two myocardial infarctions and 6 had chronic renal dysfunction including two requiring hemodialysis. On-pump operations were performed in all cases with a mean CPB time of 104.2∓29.7 min and cross clamping time of 69.0∓21.3 min. Cold blood or HTK cardioplegia was used for myocardial protection. The left internal mammary artery (LIMA) was routinely anastomosed to the left anterior descending artery (LAD), and the great saphenous vein (GSV) to other target vessels. The mean number of grafts was 2.9∓0.6.Forty-one patients were cured and discharged and 4 patients died with an in-hospital mortality of 8.9%, including one associated with cardiac event (2.2%). IABP was weaned off within 28.5∓10.6 h after surgery except for one patient who died of multiple organ and system failure (MOSF). Thirty-eight patients (92.7%) were followed up for a mean of 37.3∓16.7 months, during which 2 patients died with a mid-term survival rate of 94.7%. Thirty-five (92.1%) patients had New York Heart Association (NYHA) class I and II. The freedom from cardiac event was 90.5%. Follow-up echocardiography showed significantly improved left ventricular dimension and ejection fraction in these cases (P0.05), and graft patency was 95.8% for the LIMA and 90.5% for the GSV.Despite a slight increase of the in-hospital mortality, ECABG can improve the mid-term survival, freedom from cardiac event, and cardiac function when the indications and timing for surgery are well controlled with optimal perioperative management.

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.

To retrospectively assess the value of intraoperative transesophageal echocardiography (TEE) during robotic mitral valve (MV) replacement.Intraoperative TEE was performed in 21 patients undergoing robotic MV replacement for severe rheumatic mitral stenosis between November 2008 and December 2010. During the procedure, TEE was performed to document the mechanism of rheumatic mitral stenosis (leaflet thickening and calcification, commissural fusion or chordal fusion) before cardiopulmonary bypass (CPB). During the establishment of peripheral CPB, TEE was used to guide the placement of the cannulae in the inferior vena cava (IVC), superior vena cava (SVC), and ascending aorta (AAO). After weaning from CPB, TEE was performed to evaluate the effect of the procedure.Accuracy of TEE was 100% for rheumatic mitral stenosis. All the cannuli in the SVC, IVC and AAO were located in the correct position. In all patients, TEE confirmed successful procedure.TEE is useful in the assessment of robotic MV replacement.

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.

To compare the blood flow in sequential and individual saphenous vein grafts (SVGs) and to analyze the influence of the location of the target vessel in off-pump coronary artery bypass grafting (OPCAB).A total of 464 SVGs in 412 patients receiving OPCAB were nested into individual SVG (n=206), double (n=241) or triple sequential SVG (n=15), and analyzed.The blood flow in double and triple SVGs was significantly higher than in individual SVGs [(43.4±22.5), (43.7±19.2) and (28.9±18.7) mL/min, respectively, P0.001, P=0.047]. There were no differences between flow in double and triple SVGs (P=0.96). Pulsatility index (PI) of the three groups were similar (2.6±1.2, 2.5±1.6, 2.8±0.9, respectively, P=0.49, P=0.49). In individual SVGs to right coronary artery, the blood flow was higher than in the posterior descending branch (PDA) (P=0.047) and posterior branch of left ventricle (PBLV), the flow-time in systole period was longer than diagonals (P=0.003), obtuse marginal (OM) (P=0.013) and PDA (P=0.002), PI was significantly lower than PDA (P=0.033) and PBLV (P=0.032). The blood flow in individual SVGs to diagonals was significantly lower than in other target vessels except for PBLV (P0.05). Flow in double SVGs to PDA-PBLV was significantly lower than in PDA-OM.The mean blood flow in double and triple sequential SVGs is about 1.5 times higher than in individual SVGs. Individual, double, and triple SVGs have similar pI. Flow in individual SVGs to diagonals was significantly lower than in other target vessels except for PBLV.

To summarize the experience with the application of robotic technique in totally endoscopic atrial septal defect closure in a single center.Between January 2007 and September 2011, 115 patients with the diagnosis of secundum type atrial septal defects underwent robotic atrial septal defect repair with the assistance of da Vinci surgical system. The patients had a median age of 35 years and a median defect diameter of 28 mm. Cardiopulmonary bypass was established via peripheral cannulation. Via three 8-mm ports and one 15-mm port in the right chest, the surgeon manipulated the microinstruments to complete the defect closure with or without tricuspid valve plasty. Echocardiography was performed intraoperatively, before discharge and at 30 days after the operation.Atrial septal defect closure was completed on arrested heart in 44 patients and on beating heart in 61 patients. No deaths or conversions to alternate techniques occurred in these cases. No residual shunt was detected by intraoperative or postoperative echocardiography. The mean operating time and cardiopulmonary bypass time on bearing heart group were significantly shorter than those on arrested heart group. The median ventilation time, intensive care unit stay, drainage volume, or length of hospital stay showed no significant differences between the two groups.Secundum type atrial septal defect closure can be successfully performed with the assistance of the robotic system with good surgical results.