Robotic mitral surgery is one of the most common robotic cardiac procedures being performed, which presents many benefits including smaller incisions, less postoperative pain, quicker recovery, decreased blood transfusion requirements for the patient, better exposure and better visualization of the mitral valve, and increased operative dexterity for the surgeon. As redo robotic mitral operations have increased in number, the use of atrial and ventricular sumps have also increased, especially during cases done under fibrillation. Our practical and easy-to-implement technique that consists of transpericardial atrial and ventricular vent placement during robotic mitral procedures may prevent dislodgement of the vents and may be beneficial to avoid important complications such as air embolisms and left ventricular distension resulting in subendocardial ischaemia.

Coronary artery bypass grafting via median sternotomy carries considerable morbidity, and minimally invasive robotic approaches have been increasingly performed for surgical revascularization of coronary arteries. We report our institutional experience in robotic-assisted minimally invasive coronary revascularization in a broad patient population with complex multivessel disease. We retrospectively reviewed robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) procedures performed at our center between January 2022 and June 2026. Patient demographics, additional procedures and in-hospital outcomes were recorded. A total of 242 patients were included (mean age 63.4 ± 9.7 years; 31 (12.8%) female). Single-vessel bypass was performed in 25 (10.3%) patients; 212 (87.6%) patients underwent an operation on the arrested heart (mean cross-clamp time 66.9 ± 21.7 min) and 15 (6.2%) received an off-pump operation (mean CPB time in on-pump patients 155.7 ± 46.0 min). Full arterial revascularization was achieved in 42 (17.4%) patients; a bilateral internal mammary artery configuration was used in 9 (3.7%) patients. Coronary endarterectomy was performed in 16 (6.6%) patients and concomitant left atrial appendage (LAA) occlusion was performed in three (1.2%) patients. Epiaortic ultrasonography-guided clamp placement was performed in 27 (11.2%) patients with ascending-aortic plaque. In-hospital mortality occurred in two (0.8%) patients; no patient sustained a major neurological deficit, and the transfusion rate was 9.9%. Mean ventilation time was 4.0 (3.0–6.0) hours and mean intensive care unit stay was 22.6 ± 11.2 h. With careful planning and accumulated experience, the indications for robotic-assisted minimally invasive revascularization can be extended to include patients who require full-arterial revascularization, have ascending aortic plaques, complex coronary disease requiring endarterectomy, or atrial fibrillation where concomitant left atrial appendage occlusion is indicated.

Background/Objectives: Whether PCCT-derived virtual non-iodine (VNI) images can replace true non-contrast (TNC) for coronary artery calcium scoring (CACS) remains uncertain, particularly for small, low-density plaques. We aimed to evaluate agreement between VNI and TNC for CACS at the patient and lesion levels and to quantify risk-category reclassification. Methods: In this retrospective single-center sample (May 2024–May 2025), 211 patients without prior coronary intervention and with nonzero CAC on TNC underwent PCCT. VNI (55 keV, QIR 1; 60 keV, QIR 4; PureCalcium) and TNC were reconstructed with matched section thickness/increment and kernel. Agatston and total calcified volume were recorded. Paired comparisons used Wilcoxon tests; reclassification across CAC categories (0, 1–99, 100–399, ≥400) and lesion-level false negatives (FNs) were assessed with TNC as the reference. Results: Low-keV VNIs (55–60 keV) underestimated CAC versus TNC. The median Agatston score decreased from 35.9 (IQR, 10.3–121.2) on TNC to 23.6 at 55 keV (p = 0.0006) and 22.2 at 60 keV (p = 0.0003); the total volume declined from 37.8 mm3 to 20.2 mm3 (p = 0.001) and 18.3 mm3 (p < 0.0001), respectively. More than half of patients were reassigned to a lower CAC category; despite no patient being CAC = 0 on TNC, 46.9% (55 keV) and 47.4% (60 keV) were labeled CAC = 0 on VNI. Because this study deliberately included only patients with nonzero CAC on the TNC reference, these CAC = 0 rates on VNI represent misclassification within a CAC-positive sample and should not be interpreted as population-level prevalence. At the lesion level, 95% of patients had ≥1 FN plaques (430 FN plaques total), typically small (median 8 mm3) and of low density (median Agatston 6). Conclusions: In this single-center sample with relatively low-burden calcification, low-keV VNI (55–60 keV) significantly underestimates CAC and down-classifies patients, with frequent “false-zero” assignments (defined as CAC_VNI = 0 despite CAC_TNC > 0) driven predominantly by small, low-density plaques.

Objective The Ozaki procedure is a technique aiming neo-cuspidation from autologous pericardium. It was mentioned that by this technique the patients can have good hemodynamic results. The objective of this study was to demonstrate a reduction in the pressure gradient in the aortic valve following the Ozaki procedure in subjects with a small aortic annulus. Design and method In this retrospective study, the patients who underwent the Ozaki procedure between January 2020 and December 2024 in a single center were analyzed. Patients diagnosed with aortic regurgitation without aortic stenosis, and those with an aortic annulus greater than 23 mm, were excluded from the study. The patients' demographic and preoperative values were analyzed. All data were retrieved from the clinical database and intraoperative transesophageal echocardiography reports and views. Results and conclusions Thirty-five patients underwent surgery using the Ozaki technique, of whom 19 were female and 16 male. Concomitant procedures were performed in 15 patients. The mean age was 67.6 ± 2.4 years. The mean EuroSCORE II score was 5.5 ± 2.4. The aortic annulus measured 23 mm in 13 patients, 22 mm in 8 patients, 21 mm in 7 patients, 20 mm in 4 patients, and 19 mm in 3 patients. The peak aortic valve pressure gradient was 74.1 ± 15.3 mmHg, and the mean pressure gradient was 46.5 ± 10.9 mmHg. After the Ozaki procedure, the peak aortic valve pressure gradient was recorded at 12.3 ± 4.7 mmHg, with a mean gradient of 6.1 ± 3.4 mmHg. No instances of moderate or severe aortic regurgitation were observed in any of the patients. The cardiopulmonary bypass time was 125.6 ± 25.8 minutes, and the cross-clamp time was 101.9 ± 22.4 minutes. The duration of the intensive care unit stay was 24.1 ± 12.1 hours, and the hospital stay was 8.1 ± 4.3 days. There was no hospital mortality.A plethora of manufactured aortic valves, encompassing both biological and mechanical types, were available. As stated in the product materials, the peak gradient in mechanical valves is greater than 40 mmHg, and the mean gradient is greater than 18 mmHg in valves with a diameter of 19 mm. In the case of biological valves, the mean gradient is greater than 13 mmHg in 19 mm diameter.The pressure gradient decreases with the enlargement of the prosthetic valves, as would be expected.In the present cohort of patients, the peak and mean gradient are observed to be considerably lower than the prosthesis valves.Therefore, the Ozaki procedure provides excellent hemodynamic and clinical results.

Photon-counting detector computed tomography (PCD-CT) employs direct-conversion detectors that record the arrival and energy of individual photons, enabling high-resolution, multi-energy cardiovascular imaging. We searched MEDLINE, Embase, and Scopus from January 2021 through September 2025 and included 59 studies. Owing to heterogeneity in study designs, protocols, and endpoints, the findings were synthesized narratively across five domains (coronary, myocardial, structural/valvular, pulmonary-cardiopulmonary function, and aortic/visceral/peripheral arteries). In coronary imaging, a routine-practice cohort (n = 7.833) reported a per-patient specificity of 98% vs. 93%, lower invasive angiography of 9.9% vs. 13.1%, and a higher revascularization yield of 43.4% vs. 35.5% [PCD-CT vs. energy-integrating detector CT (EID-CT); ultra-high-resolution protocols achieved a vessel-level area under the curve (AUC) of up to 0.99. Low-dose CCTA was feasible at a CTDIvol of 1.72 mGy, and contrast-saving protocols supported diagnostic studies with a volume of 30 mL. Virtual non-contrast calcium scoring showed an intraclass correlation coefficient of 0.98 vs. true non-contrast. In myocardial tissue characterization, PCD-CT-derived extracellular volume differed from cardiovascular magnetic resonance by ≤2% in selected cohorts, with a kappa of up to 0.956 for late-enhancement agreement; segment-level inflammation classification reached an AUC of 0.95. For structural/valvular assessment, a comparative cohort reported an effective dose of 8.8 ± 4.5 vs. 15.3 ± 5.8 mSv, with visual image quality scores of 4.8 vs. 3.3, respectively, for PCD-CT vs. EID-CT. Lung-perfusion iodine maps for chronic thromboembolic pulmonary hypertension achieved an accuracy of 0.85-0.88 at approximately one-fifth of the dose of single-photon emission CT. For aortic/peripheral applications, thoracoabdominal protocols reported a dose of 4.2 ± 1.4 vs. 7.2 ± 2.2 mGy, with a higher signal-to-noise ratio/contrast-to-noise ratio (PCD-CT vs. EID-CT); infrapopliteal imaging used 60 versus 140 mL of contrast, respectively, with improved vessel sharpness for PCD-CT vs. EID-CT; diagnostic performance for peripheral stenosis reached a sensitivity of 91% and a specificity of 95%, respectively, when compared with digital subtraction angiography. Overall, the evidence-predominantly single center-indicates that PCD-CT may enable dose- and contrast-efficient cardiovascular imaging with strong diagnostic metrics, and confirmation in multicenter outcome and cost-effectiveness studies remains a priority.

Objective Peripheral arterial and venous cannulation is the essential site for cardiopulmonary bypass (CPB) in Robotic-assisted and minimally invasive coronary artery bypass graft surgery. The cannulae employed in this procedure are of a smaller size than those utilized in conventional coronary artery bypass graft (CABG) surgery. Consequently, the process of tissue perfusion can prove to be a challenging endeavor.The objective of this study is to make a comparison between the perfusion parameters in on-pump minimally invasive and conventional coronary artery bypass graft (CABG) surgery using the Spectrum Medical Quantum cardiopulmonary bypass machine. Design and method In this retrospective study, we analyzed the on-pump isolated CABG surgery patients that used Spectrum Medical Quantum CPB machines from October 2022 to December 2024. A total of 130 patients underwent on-pomp isolated CABG surgery. Patients were separated into 2 groups: Group R robotic-assisted surgery (n=87), and Group S, sternotomy surgery (n=43). Demographic data, intraoperative, postoperative values, and perfusion values were compared between the two groups. All data was extracted from the database of our clinic and the CPB machine database. The indexed oxygen extraction ratio (O2ERi) was compared at fifth minutes after cross-clamping, as well as at 20 and 40 minutes, and 60 minutes after cross-clamping. Additionally, the ratio was compared at five minutes before and 20 minutes after cross-clamp removal. Results and conclusions There were no significant differences between the groups in demographic values. Table 1. Euroscore is higher in Group S than in Group R (3.2 vs 1.9, p<0.01). There was no difference in cross-clamp time however CPB time was longer in Group R, attributed to the duration of proximal anastomosis. The mean arterial pressure of the pump in the cannulas was found to be higher in Group R than in Group S (238.6 mmHg vs. 167.8 mmHg, p < 0.001). Because the size of peripheral cannulas was smaller than the central cannulas (mean 19 Fr vs mean 22 Fr ). There were no differences in O2ERi levels and lactate levels between groups, in Figure 1 and Figure 2 (p>0.05). There were no significant differences in Hb levels during CPB period between groups. (10.5 ±1.8 vs 10.2 ± 1.8, p=0.67) There were no significant differences in intensive care unit and hospital stay between the groups.In conclusion, this retrospective observational study demonstrated that the perfusion with peripheral cannulas is as effective as central cannulation perfusion.

BACKGROUND:Robotic assistance has many advantages in minimally invasive coronary bypass surgery, such as the harvest of a longer portion of the LIMA in addition to the avoidance of sternotomy, thus offering a less invasive approach for multivessel revascularisation. We present the midterm clinical outcomes of robotic-assisted minimally invasive coronary bypass (RA-CABG) cases at our centre. METHODS:One hundred and fifty consecutive patients who underwent RA-CABG with preoperative computed tomography angiography guidance were studied. Robotic LIMA harvesting was performed. The main outcome measure of the study was the midterm survival and incidence of major adverse cardiovascular events (MACE) up to 5 years. RESULTS:The median follow-up was 19.8 months. In the Kaplan-Meier survival analysis, 1-year survival was 99.1% and 5-year survival was 97.5%. 1-year freedom from MACE was 97.3% and 5-year freedom from MACE was 95%. CONCLUSIONS:Robotic-assisted minimally invasive coronary bypass surgery has safe midterm outcomes and can be performed with excellent results.

OBJECTIVE:Robot-assisted minimally invasive coronary bypass surgery is one of the least invasive approaches that offers multivessel revascularization and accelerated recovery. We investigated the benefits of computed tomography angiography (CTA) guidance in robotic coronary bypass (RCAB) by analyzing perioperative outcomes.METHODS:Between April 2022 and April 2023, 60 consecutive patients who underwent RCAB under preoperative CTA guidance were included. The intercostal space of the minithoractomy incision was determined based on the distance from the thoracotomy site to the midsection of the left anterior descending artery (LAD) on preoperative CTA. Peripheral vascular findings on preoperative CTA guided the decision for the cannulation site. Perioperative parameters and early outcomes were evaluated.RESULTS:The mean age of the patients was 62.3 ± 10.5 years, and 51 patients were male (85.0%). The mean number of revascularized vessels was 2.9 ± 1.1. Left thoracotomy guided by CTA measurements was performed in the fourth intercostal space in 37 patients (61.7%) and in the third intercostal space in the remaining patients. Axillary cannulation was performed in 28 (46.7%) patients because of prohibitive findings in the iliac vessels and aorta. All target coronary arteries with an indication for bypass were revascularized with CTA-guided RCAB. The left internal mammary artery (LIMA) was anastomosed to the LAD in all patients, and the LIMA was anastomosed sequentially to the diagonal artery in 17 patients (28.3%). No operative mortality or cerebrovascular event was observed. One patient underwent reoperation due to bleeding.CONCLUSIONS:Robot-assisted minimally invasive multiple-vessel coronary bypass under preoperative CTA guidance is safe and can be performed with excellent results.

Robotic-assisted minimally invasive multiple vessel coronary bypass surgery is safe and can be performed with excellent results. In this video tutorial, we present our technique for robotic-assisted minimally invasive multivessel coronary artery bypass grafting, with complete coronary revascularization via a left anterior thoracotomy and guided by preoperative computed tomography.

OBJECTIVE:The aim of this study was to investigate the outcomes of robotic mitral valve surgery with and without concomitant tricuspid valve surgery.METHODS:Patients who underwent robotic mitral surgery between March 2010 and September 2022 were included. Patients were grouped according to the presence of concomitant tricuspid interventions. The groups were compared for baseline factors, operative parameters, and early postoperative outcomes. Age- and gender-matched groups were also compared for outcomes.RESULTS:The study included 285 robotic mitral surgery patients. There were 59 patients who underwent concomitant tricuspid interventions. In the concomitant tricuspid surgery group, cardiopulmonary bypass time (150.1 vs 128.4 min, P < 0.001) and cross-clamp time (99.2 vs 82.4 min, P < 0.001) were longer. Prolonged intubation was more frequent in the concomitant tricuspid intervention group (5.2% vs 0.5%, P = 0.029). The groups did not differ in terms of mortality, permanent pacemaker (PPM) requirement, or other morbidities. Perioperative outcomes were similar after matched group analysis.CONCLUSIONS:Operative mortality and early adverse outcomes did not increase with the addition of tricuspid intervention in our cohort of robotic mitral surgery patients. The robotic approach for mitral disease and coexisting tricuspid disease may offer safe results without an increased risk of postoperative PPM requirement.

Achievement of complete hemostasis is a key element to success in cardiac surgery. Bleeding control is of utmost importance in minimally invasive and robotic cardiac surgery to avoid conversion, as major bleeding is one of the most common indications for conversion to sternotomy. Bleeding control with surgical techniques can be technically more difficult in robotic and minimally invasive cardiac surgery as access to the bleeding area is limited and it is harder to intervene compared with open cardiac surgery with sternotomy. We present in this case the achievement of hemostasis in a minimally invasive robotic mitral repair, without the employment of surgical techniques and with the aid of a surgical sealant.

Mitral valve replacement is a method in patients with severe valve disease who have no chance of valve repair. The advantages of minimally invasive techniques during mitral valve operations have been demonstrated in many studies. Robotic assisted surgery is the technological ultimate in minimally invasive surgery and provides a minimal surgical trauma for the patients and a better surgical exposure for the surgeon. The dexterity of robotic instruments with the capacity of high degree rotation mimics surgeon wrist. The endoscope can get very close to the surgical field and the mitral valve, and with its zoom in and out features, it provides more control of the sub -valve structures than conventional surgery. The robotic left atrial retractor assists the surgeon not only in left atrium but also at many points. Thanks to this feature, the robotic left atrial retractor is different and useful from the conventional minimally invasive retractors. Robot also helps surgeon to suppress tremors during reconstruction. All these factors may assure a more effective and safer mitral valve repair/replacement with robotic surgery. The adoption of robotic techniques was quite slowly in cardiac surgery comparing to other specialities. This might be related to cost, longer learning curve, and the necessity of a large team with patience, perseverance and dedication. In this section, the technical details of robotic assisted mitral valve replacement will be presented and enriched with video images. Some tips in the article may help surgical teams who are new to robotic surgery to perform a safer and faster surgery.

Background:The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping.Methods:From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded.Results:Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients.Conclusions:Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.

Objective:Red blood cell (RBC) transfusion in cardiac surgery is associated with increased morbidity and mortality. Even when using patient blood management methods, blood transfusions may still be needed in cardiac surgery. This study examined the risk factors for blood transfusion in isolated coronary artery bypass graft (CABG) surgery with a restrictive transfusion strategy, along with individualized patient blood management.Methods:We enrolled 198 patients (age, 61.8 ± 9.9 years; 28 females and 170 males) who underwent isolated CABG surgery in a single private hospital using a restrictive transfusion strategy between April 2015 and October 2020. Pre-, intra-, and postoperative parameters were compared between patients with and without RBC transfusions. The risk factors for transfusion and transfusion probability were analyzed.Results:Patients who received RBC transfusions had higher European System for Cardiac Operative Risk Evaluation values (13.60 ± 18.27%). Preoperative hematocrit (Hct) [odds ratio (OR)=0.752; 95% confidence interval (CI) 0.639-0.884; P=0.001] and female gender (OR=7.874; 95% CI 1.678-36.950; P=0.009) were significant independent risk factors for RBC transfusion in logistic regression analysis. When the preoperative Hct was 30%, the RBC transfusion probability was 61.08% in females and 16.6% in males. Patients who received RBC transfusions had longer intensive care unit (31.40 ± 25.42 hours) and hospital (11.18 ± 6.75 days) stays.Conclusion:Risk factors for RBC transfusion in isolated CABG surgery with a restrictive blood transfusion strategy were preoperative anemia and female gender.