A solenoid injector based drop-on-demand system for generating large droplets.

This paper proposes a drop-on-demand (DOD) system that can produce single droplets of highly repeatable size in the order of 2 mm. This system utilizes an on-the-shelf solenoid injector used in automotive applications. The design methodology is explained along with the necessary measurements and numerical simulations of droplet generation. The invention consists of a solenoid injector that produces monodisperse single or in-series droplets with the help of a developed pulse width modulated signal generator. Mass per injection is measured over a range of supply pressures and injection durations to find the operation window to generate 2 mm droplets. Later, various nozzle geometries are designed and tested by flow simulations. The contracting nozzle is found suitable for generating single droplets, so the design is implemented at the tip of the solenoid injector. The effects of different opening times, pressures, and nozzle's orifice diameters were tested to observe the operating window of the newly designed DOD system and the repeatability of generated droplets by utilizing a coherent circular Hough transform image processing algorithm to measure droplet sizes. The standard deviation of measured diameters is less than 5% of the mean droplet diameter, which is in the range of 1.68-2.07 mm. Next, the voltage and current signals are measured per injection, and exact instants for the initiation and ending for both opening and closing are determined to construct transient mass flow rate functions for flow simulations in which the dependence of droplet formation on the speed of closing is revealed. The numerical and experimental results indicate the repeatability and consistency of the invention.

Custodiol versus Blood Cardioplegia: Comparison of Myocardial Immunohistochemical Analysis and Clinical Outcomes

ABSTRACT Introduction: Custodiol (histidine-tryptophan-ketoglutarate) and repetitive blood cardioplegia are the solutions for myocardial protection and cardiac arrest. In this study, we aimed to compare immunohistochemical analysis, clinical outcomes, and cardiac enzyme values of Custodiol and blood cardioplegia groups. Methods: This was a randomized prospective study consisting of 2 groups and 20 patients, 10 patients for each group, who underwent mitral and mitral/tricuspid valve surgery. Group 1 was formed for Custodiol cardioplegia and group 2 for blood cardioplegia. Perioperative and postoperative cardiac events were recorded, cardiac enzymes were analyzed with intervals, and myocardial samples were taken for immunohistochemical analysis. Recorded data were statistically evaluated. Results: There was no significant difference for the Custodiol and blood cardioplegia groups in perioperative and postoperative cardiac performance and adverse events. Cardiac enzyme analysis showed no significant difference between groups. However, two parameters (eNOS, Bcl-2) were in favor of the Custodiol group in immunohistochemical studies. Custodiol performed better in cellular oxidative stress resistance and cellular viability. Conclusion: Clinical outcomes and cardiac enzyme analysis results were similar regarding myocardial protection. However, Custodiol performed better in the immunohistochemical analysis.

Evidence for a HURP/EB free mixed-nucleotide zone in kinetochore-microtubules.

Current models infer that the microtubule-based mitotic spindle is built from GDP-tubulin with small GTP caps at microtubule plus-ends, including those that attach to kinetochores, forming the kinetochore-fibres. Here we reveal that kinetochore-fibres additionally contain a dynamic mixed-nucleotide zone that reaches several microns in length. This zone becomes visible in cells expressing fluorescently labelled end-binding proteins, a known marker for GTP-tubulin, and endogenously-labelled HURP - a protein which we show to preferentially bind the GDP microtubule lattice in vitro and in vivo. We find that in mitotic cells HURP accumulates on the kinetochore-proximal region of depolymerising kinetochore-fibres, whilst avoiding recruitment to nascent polymerising K-fibres, giving rise to a growing "HURP-gap". The absence of end-binding proteins in the HURP-gaps leads us to postulate that they reflect a mixed-nucleotide zone. We generate a minimal quantitative model based on the preferential binding of HURP to GDP-tubulin to show that such a mixed-nucleotide zone is sufficient to recapitulate the observed in vivo dynamics of HURP-gaps.

Kinetochore tracking in 3D from lattice light-sheet imaging data with KiT.

MOTIVATION: Lattice light-sheet microscopy (LLSM) is revolutionizing cell biology since it enables fast, high-resolution extended imaging in three dimensions combined with a drastic reduction in photo-toxicity and bleaching. However, analysis of such datasets still remains a major challenge. RESULTS: Automated tracking of kinetochores, the protein complex facilitating and controlling microtubule attachment of the chromosomes within the mitotic spindle, provides quantitative assessment of chromosome dynamics in mitosis. Here, we extend existing open-source kinetochore tracking software (KiT) to track (and pair) kinetochores throughout prometaphase to anaphase in LLSM data. One of the key improvements is a regularization term in the objective function to enforce biological information about the number of kinetochores in a human mitotic cell, as well as improved diagnostic tools. This software provides quantitative insights into how kinetochores robustly ensure congression and segregation of chromosomes during mitosis. AVAILABILITY AND IMPLEMENTATION: KiT is free, open-source software implemented in MATLAB and can be downloaded as a package from https://github.com/cmcb-warwick/KiT. The source repository is available at https://bitbucket.org/jarmond/kit (tag v2.4.0) and under continuing development. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Custodiol versus Blood Cardioplegia: Comparison of Myocardial Immunohistochemical Analysis and Clinical Outcomes.

INTRODUCTION: Custodiol (histidine-tryptophan-ketoglutarate) and repetitive blood cardioplegia are the solutions for myocardial protection and cardiac arrest. In this study, we aimed to compare immunohistochemical analysis, clinical outcomes, and cardiac enzyme values of Custodiol and blood cardioplegia groups. METHODS: This was a randomized prospective study consisting of 2 groups and 20 patients, 10 patients for each group, who underwent mitral and mitral/tricuspid valve surgery. Group 1 was formed for Custodiol cardioplegia and group 2 for blood cardioplegia. Perioperative and postoperative cardiac events were recorded, cardiac enzymes were analyzed with intervals, and myocardial samples were taken for immunohistochemical analysis. Recorded data were statistically evaluated. RESULTS: There was no significant difference for the Custodiol and blood cardioplegia groups in perioperative and postoperative cardiac performance and adverse events. Cardiac enzyme analysis showed no significant difference between groups. However, two parameters (eNOS, Bcl-2) were in favor of the Custodiol group in immunohistochemical studies. Custodiol performed better in cellular oxidative stress resistance and cellular viability. CONCLUSION: Clinical outcomes and cardiac enzyme analysis results were similar regarding myocardial protection. However, Custodiol performed better in the immunohistochemical analysis.

Kinetochore life histories reveal an Aurora-B-dependent error correction mechanism in anaphase.

Chromosome mis-segregation during mitosis leads to aneuploidy, which is a hallmark of cancer and linked to cancer genome evolution. Errors can manifest as "lagging chromosomes" in anaphase, although their mechanistic origins and likelihood of correction are incompletely understood. Here, we combine lattice light-sheet microscopy, endogenous protein labeling, and computational analysis to define the life history of >104 kinetochores. By defining the "laziness" of kinetochores in anaphase, we reveal that chromosomes are at a considerable risk of mis-segregation. We show that the majority of lazy kinetochores are corrected rapidly in anaphase by Aurora B; if uncorrected, they result in a higher rate of micronuclei formation. Quantitative analyses of the kinetochore life histories reveal a dynamic signature of metaphase kinetochore oscillations that forecasts their anaphase fate. We propose that in diploid human cells chromosome segregation is fundamentally error prone, with an additional layer of anaphase error correction required for stable karyotype propagation.

Mediastinitis after cardiac surgery: risk factors and our vacuum-assisted closure results.

INTRODUCTION: Mediastinitis after cardiac surgery is a rare complication, but with high morbidity and mortality. AIM: To determine its risk factors and to investigate the efficacy of vacuum-assisted closure (VAC). MATERIAL AND METHODS: Nine thousand one hundred sixty cases of patients who underwent cardiac surgery during 2010-2017 were reviewed retrospectively. One hundred and twenty-seven patients, the case group, were treated by VAC. Three hundred cases with no diagnosis of mediastinitis were selected as the control group. Both groups' clinical and demographic characteristics, preoperative variables, and postoperative follow-up parameters were compared. Factors affecting treatment were analyzed. RESULTS: We found that the presence of diabetes mellitus, bilateral internal thoracic artery and intra-aortic balloon pump usage are independent risk factors for the development of mediastinitis (p < 0.05). It was found that 74% of tissue cultures were positive and the most common detected organism was Staphylococcus. It was found that many perioperative parameters had a significant effect on the duration of treatment (p < 0.05). However, regression analysis revealed that bacterial growth was the only independent variable in prolonging the treatment period. CONCLUSIONS: We believe that the establishment of perioperative blood glucose regulation, patient selection to use bilateral internal thoracic artery grafts, and maximum attention to sepsis and antisepsis rules in patients who need mechanical support devices such as intra-aortic balloon pump, will significantly reduce the development of mediastinitis. Since we could not find an independent risk factor for the duration of VAC treatment other than culture growth, we think that VAC therapy is successful and safe in the treatment of mediastinitis and should be used more widely.

Left ventricular apical thrombi: Silent but terrifying.

We present a case with a large left ventricular (LV) thrombus that presented to the emergency department with dyspnea. Bedside transthoracic echocardiography demonstrated a huge hypermobile thrombus with a maximum of 8.6 × 2 cm in size extending to the aortic valve originating from the aneurysmatic apical wall of the LV. Treatment of the patient included complete thrombus resection with aneurysmectomy.

A comparison of robotically-assisted endoscopic versus sternotomy approach for myxoma excision: A single-center experience.

BACKGROUND: In this study, we present our single-center experience in robotically-assisted endoscopic surgery versus conventional median sternotomy approach in patients undergoing cardiac myxoma excision. METHODS: Between January 2011 and September 2019, a total of 46 patients (24 males, 22 females; mean age 54.1±12.5 years; range, 25 to 79 years) who had a confirmed diagnosis of isolated cardiac myxoma were included in the study. The patients were divided into two groups as those undergoing robotic-assisted surgery (n=16) and those undergoing conventional median sternotomy (n=30). Clinical characteristics, operative, and postoperative outcomes were compared. Robotic approach to right or left-sided tumors and postoperative pain scores were also analyzed. RESULTS: There was no mortality or major complication. No conversion to sternotomy was needed in robotic procedures. The mean cardiopulmonary bypass and aortic cross-clamp times were significantly shorter in the median sternotomy group (p=0.001 for both). The mean ventilation time and the length of hospital stay were significantly shorter in robotic surgery than sternotomy group (p=0.043 and p=0.048, respectively). The mean amount of postoperative blood loss and transfusion rate were significantly lower in robotic surgery patients (p=0.001 and p=0.022, respectively). The mean postoperative pain scores were significantly lower in patients undergoing robotic surgery (p=0.022). CONCLUSION: Robotic-assisted endoscopic surgery can be performed safely and effectively for cardiac myxoma excision with shorter hospital stay, less pain, and less amount of blood product use, as well as more favorable cosmetic results compared to conventional median sternotomy.

Effects of pulmonary perfusion during cardiopulmonary bypass on lung functions after cardiac operation.

BACKGROUND: Pulmonary artery perfusion during cardiopulmonary bypass (CPB) is a known but rarely used technique in adult cardiac surgery. In this study, we aimed to investigate biochemical and histopathological effects of pulmonary artery perfusion during CPB on lung functions. METHODS: Between May 2014 and August 2014, all patients (n = 24) who gave informed consent for participating this study with inclusion criteria were included. Patients undergoing isolated coronary artery bypass grafting were sequentially randomized to conventional CPB (control group, n = 12) and conventional CPB with selective pulmonary artery perfusion (study group, n = 12). Lung functions were monitored using PF ratio, alveolar-arterial oxygen gradient, and lactate levels. A small sample tissue from the left lung was excised for histopathologic examination. Immunocytochemistry analysis was performed using anti-rabbit polyclonal vascular endothelial growth factor (VEGF), rabbit polyclonal inducible nitric oxide synthase (i-NOS), and BCL-2 antibodies. RESULTS: Postoperative course of the patients were uneventful without any clinical outcome differences in terms of cardiopulmonary complications, ventilation time and hospital stay. Pulmonary perfusion group had significantly better oxygenation values after extubation and at postoperative 24-hour. Electron microscopy examinations revealed better preservation of the alveolar wall integrity with pulmonary perfusion. The intensity of VEGF, i-NOS, and BCL-2 antibody expressions in bronchial epithelial cells were more prominent in the pulmonary perfusion group. CONCLUSIONS: Pulmonary artery perfusion during aortic cross-clamping provides better oxygenation and preservation of the wall alveolar integrity after coronary artery bypass grafting surgery. This technique can be used as a protective strategy to minimize CPB-induced lung injury in adult cardiac surgery.

Effect of Pulsatile Cardiopulmonary Bypass in Adult Heart Surgery.

BACKGROUND: This study aimed to examine the effect of pulsatile flow pattern on tissue perfusion, particularly cerebral tissue perfusion, at pre-determined intervals during CPB, as well as its effects on postoperative morbidity and mortality. METHODS: This retrospective study included 134 adult patients, who underwent cardiac surgery with cardiopulmonary bypass (CPB). Patients were grouped based on the flow pattern used during CPB: non-pulsatile CPB group (N = 82) and pulsatile CPB group (N = 52). Cerebral oxygen saturation, arterial pH and arterial lactate levels were measured at four time points, during the operation and the 2 groups were compared with regard to changes over time as well as differences in postoperative outcomes. RESULTS: The 2 groups were similar, in terms of mean values and intraoperative changes in cerebral oxygen saturation and arterial pH. Non-pulsatile CABG group had significantly higher arterial lactate levels over the measurement period, which was not affected by the timing of the measurements. Postoperative drainage, duration of ventilation and duration of hospital stay significantly were higher and postoperative blood urea nitrogen significantly was lower in the non-pulsatile CPB group. Other postoperative outcomes were similar across the groups. CONCLUSION: Findings of this study do not support the superiority of pulsatile flow pattern during CPB, in terms of cerebral oxygen saturation or postoperative mortality/morbidity. Further and larger comparative studies are warranted before pulsatile blood flow pattern can be established as a routine clinical method.

Robotic-assisted cardiac surgery without lung isolation utilizing single-lumen endotracheal tube intubation.

OBJECTIVES: This study assessed the feasibility and outcomes of performing robotic cardiac surgery without lung isolation using single-lumen (SL) endotracheal tube intubation. METHODS: Between 2013 and 2017, 132 patients underwent robotically-assisted atrial septal defect closure. A retrospective analysis was performed of 23 patients (11 males, mean age 30.9 ± 5 years) who underwent robotic surgery with double-lumen (DL) endotracheal tube intubation (group 1) compared with 109 patients (57 males, mean age 32.4 ± 7.5 years) undergoing the same procedure with SL endotracheal intubation (group 2). The patient groups were compared in terms of demographic characteristics, operative data, and complications. The technical feasibility of the robotic procedure without lung isolation was evaluated. RESULTS: There were no mortality, intraoperative complication, and conversion. Mean total anesthesia time was significantly decreased in the SL intubation group (238.3 ± 22.4 vs 227.2 ± 21.2 minutes; P = .025). First-pass intubation success was significantly higher in the SL intubation group (17 [73.9%] vs 98 [89.9%] patients; P = .032). Mean ventilation time (10.9 ± 5.3 hours), intensive care unit stay (16.8 ± 10.1 hours), and the length of hospital stay (3.8 ± 1.2 days) was significantly decreased in patients with SL tube (P < .05). Unilateral reexpansion pulmonary edema was observed in five (21.7%) patients with DL tube, whereas no patient with SL tube had this complication. CONCLUSIONS: SL endotracheal tube intubation without lung isolation is a feasible and safe airway alternative in robotic cardiac procedures. This approach resulted in shorter anesthesia time, ventilation time and the length of hospital stay. Port placement and robotic set-up can be uneventfully performed without lung isolation.

Kinase inhibition profiles as a tool to identify kinases for specific phosphorylation sites.

There are thousands of known cellular phosphorylation sites, but the paucity of ways to identify kinases for particular phosphorylation events remains a major roadblock for understanding kinase signaling. To address this, we here develop a generally applicable method that exploits the large number of kinase inhibitors that have been profiled on near-kinome-wide panels of protein kinases. The inhibition profile for each kinase provides a fingerprint that allows identification of unknown kinases acting on target phosphosites in cell extracts. We validate the method on diverse known kinase-phosphosite pairs, including histone kinases, EGFR autophosphorylation, and Integrin ß1 phosphorylation by Src-family kinases. We also use our approach to identify the previously unknown kinases responsible for phosphorylation of INCENP at a site within a commonly phosphorylated motif in mitosis (a non-canonical target of Cyclin B-Cdk1), and of BCL9L at S915 (PKA). We show that the method has clear advantages over in silico and genetic screening.

Right pericardial window opening: a method of preventing pericardial effusion.

AIM: In this study, we aimed to investigate the superiority of right pericardial window (RPW) versus posterior pericardial drain placing for the parameters of pericardial effusion and the postoperative complications at the patients who has undergone cardiac surgery. MATERIALS AND METHODS: Between July and September 2018, 120 adult patients (mean age 50.30 ± 14.61) who underwent cardiac surgery without the necessity of opening the pleura were included in the study. In Group 1, the RPW was opened (n = 60), and Group 2 posterior pericardial drainage tube was placed without RPW (n = 60). Risk factors and postoperative complication were evaluated and compared between the Groups. RESULTS: Cardiac tamponade occurrence was not significantly different between the Groups (Group 1, n = 0 and Group 2, n = 3, p = 0.079). Postoperative transthoracic echocardiographic controls revealed significant pericardial effusion in Group 2 (6.90 mm ± 13.02 mm) compared to Group 1 (2.30 mm ± 5.60 mm) (p = 0.013). Postoperative creatinine levels were 0.75 ± 0.26 in Group 1 and 0.88 ± 0.36 in Group 2 (p = 0.022). A significant decrease in glomerular filtration rate was observed in Group 2 (102.7 ± 24.5 and 91.2 ± 28, p = 0.019). Postoperative acute renal failure was significantly higher in Group 2 compared to Group 1 (p < 0.001). Postoperative new onset atrial fibrillation occurred in 4 patients in Group 1 and 8 in Group 2 (p = 0.224). The duration of intensive care unit stay was 36.00 ± 22.31 h in Group 1 and 53.60 ± 59.50 h in Group 2 (p = 0.034). Development of pneumothorax, pneumonia and pleural effusion were not statistically different between the Groups (p = 0.079, 0.171, 0.509). CONCLUSION: RPW application is more effective on preventing postoperative complications in cardiac surgery instead of placing drains in posterior pericardium.

Robotic repair of partial anomalous pulmonary venous connection: the initial experience and technical details.

This study reports our initial experience with robotic-assisted partial anomalous pulmonary venous connection (PAPVC) repair. From May 2013 through September 2018, 20 patients (12 male and 8 female) underwent robotic-assisted repair of a right-sided (n = 19) or a left-sided (n = 1) PAPVC. The mean age was 24.6 ± 9.4 years (range 14-44) and the mean body mass index was 22.3 ± 4.6. Seventeen patients had a right-sided supra-cardiac PAPVC with sinus venosus atrial septal defect, two had a right-sided cardiac PAPVC to the right atrium and one had a left-sided cardiac PAPVC to the coronary sinus. Associated anomalies included patent foramen ovale (n = 2) and left persistent superior vena cava (n = 1). All patients were operated on successfully. No conversion to mini-thoracotomy or sternotomy was needed. Cardiopulmonary bypass and aortic clamping times were 114.8 ± 17.3 (range 90-150) and 66.5 ± 15.8 (range 44-90) minutes, respectively. Repair techniques included the single-patch repair with baffle through right atriotomy (n = 16), the 2-patch repair (n = 1) using lateral transcaval incision and intracardiac re-routing (n = 3). The mean ventilation time was 4.2 ± 1.2 h and hospital stay was 3.1 ± 0.1 days. No phrenic nerve injury, sinus node dysfunction, re-exploration or blood transfusion was noted. No residual shunting or venous obstruction was found on echocardiograms. Follow-up was a mean of 1.7 years (range 3-36 months). There was no follow-up mortality. Totally, endoscopic robotic-assisted PAPVC repair is a feasible procedure in selected adult patients. It is a less invasive alternative to traditional incisions, mini-thoracotomy and endoscopic approaches. In the future, new generation robotic devices may offer an alternative for younger patients with this pathology.

Robotic Mitral Valve Surgey Combined with Left Atrial Reduction and Ablation Procedures.

INTRODUCTION: This study aimed to evaluate the feasibility and efficacy of robotically assisted, minimally invasive mitral valve surgery combined with left atrial reduction for mitral valve surgery and elimination of atrial fibrillation (AF). METHODS: Eleven patients with severe mitral regurgitation, AF, and left atrial enlargement who underwent robotic, minimally invasive surgery between May 2013 and March 2018 were evaluated retrospectively. The da Vinci robotic system was used in all procedures. The patients' demographic data, electrocardiography (ECG) findings, and pre- and postoperative transthoracic echocardiography findings were analyzed. During follow up ECG was performed at postoperative 3, 6, and 12 months additionally at the 3rd month trans thoracic echocardiography was performed and functional capacity was also evaluated for all patients. RESULTS: All patients underwent robotic-assisted mitral valve surgery with radiofrequency ablation and left atrial reduction. Mean age was 45.76±16.61 years; 7 patients were male and 4 were female. Preoperatively, mean left atrial volume index (LAVI) was 69.55±4.87 mL/m2, ejection fraction (EF) was 54.62±8.27%, and pulmonary artery pressure (PAP) was 45.75±9.42 mmHg. Postoperatively, in hospital evaluation LAVI decreased to 48.01±4.91 mL/m2 (P=0.008), EF to 50.63±10.13% (P>0.05), and PAP to 39.02±3.11 mmHg (P=0.012). AF was eliminated in 8 (72%) of the 11 patients at the 1st postoperative month. There were significant improvements in functional capacity and no mortality during follow-up. CONCLUSION: Left atrial reduction and radiofrequency ablation concomitant with robotically assisted minimally invasive mitral valve surgery can be performed safely and effectively to eliminate AF and prevent recurrence.

The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection.

OBJECTIVES: Type A aortic dissection (TAD), which consists of an intimal tear in the aorta, necessitates emergency surgery. Various risk factors related to aortic dissection have been defined in the literature. According to our hypothesis, a narrower angle of ascending aortic curvature (AAAC) may be an additional risk factor in relation to aortic dissection due to the increased force applied to the aortic wall. METHODS: Patients undergoing ascending aortic surgery due to an ascending aortic aneurysm (AsAA) (n = 105) and patients undergoing such surgery because of the occurrence of TAD (n = 101) were enrolled in this study. The AAAC was measured using Cobb's method; the measurements were made on all patients by just 1 cardiovascular radiologist using 3-dimensional computerized tomographic imaging. This measurement was made indirectly by using the aortic valve and brachiocephalic artery to avoid obtaining misleading data as a result of distortions due to dissection. A statistical comparison was also performed relating the traditional risk factors for TAD to other clinical and echocardiographic parameters: the diameter of the ascending aorta and the AAAC. RESULTS: The AAAC was found to be narrower statistically in the TAD group (α = 76.2° ± 17.5°) than it was in the AsAA group (α = 92.9° ± 13°) (P < 0.001). Furthermore, mean ascending aortic diameter (P = 0.019), the presence of a bicuspid aorta (P = 0.007) and aortic valve stenosis (P = 0.005) were higher in the AsAA group. According to multivariable analyses, a narrower AAAC is a significant predictor for the development of TAD (odds ratio 0.93, 95% confidence interval 0.91-0.95; P < 0.001). Overall hospital mortality from various causes including stroke, myocardial infarction, bleeding or renal failure was 13% in the TAD group and 7% in the AsAA group. CONCLUSIONS: According to this study, the AAAC was significantly smaller in aortic dissection patients than in aortic aneurysm patients. This may be related to higher shear stress and elevated pressure on the ascending aorta in patients with a narrower AAAC. Thus, a narrower AAAC may be an additional risk factor in the development of TAD. Therefore, we may need to be more careful in terms of looking for the development of aortic dissection in patients with narrower AAAC.

Robotic mitral valve surgey combined with left atrial reduction and ablation procedures

Abstract Introduction: This study aimed to evaluate the feasibility and efficacy of robotically assisted, minimally invasive mitral valve surgery combined with left atrial reduction for mitral valve surgery and elimination of atrial fibrillation (AF). Methods: Eleven patients with severe mitral regurgitation, AF, and left atrial enlargement who underwent robotic, minimally invasive surgery between May 2013 and March 2018 were evaluated retrospectively. The da Vinci robotic system was used in all procedures. The patients' demographic data, electrocardiography (ECG) findings, and pre- and postoperative transthoracic echocardiography findings were analyzed. During follow up ECG was performed at postoperative 3, 6, and 12 months additionally at the 3rd month trans thoracic echocardiography was performed and functional capacity was also evaluated for all patients. Results: All patients underwent robotic-assisted mitral valve surgery with radiofrequency ablation and left atrial reduction. Mean age was 45.76±16.61 years; 7 patients were male and 4 were female. Preoperatively, mean left atrial volume index (LAVI) was 69.55±4.87 mL/m2, ejection fraction (EF) was 54.62±8.27%, and pulmonary artery pressure (PAP) was 45.75±9.42 mmHg. Postoperatively, in hospital evaluation LAVI decreased to 48.01±4.91 mL/m2 (P=0.008), EF to 50.63±10.13% (P>0.05), and PAP to 39.02±3.11 mmHg (P=0.012). AF was eliminated in 8 (72%) of the 11 patients at the 1st postoperative month. There were significant improvements in functional capacity and no mortality during follow-up. Conclusion: Left atrial reduction and radiofrequency ablation concomitant with robotically assisted minimally invasive mitral valve surgery can be performed safely and effectively to eliminate AF and prevent recurrence.

Robotic Septal Myectomy Without Anterior Leaflet Incision during Mitral Valve Repair.

Bulging subaortic septum in hypertrophic cardiomyopathy is a potential risk factor for systolic anterior motion after mitral valve repair. Systolic anterior motion may cause postoperative mitral regurgitation and left ventricular outflow tract obstruction despite conservative management. During "minimally invasive endoscopic" and "robotic" mitral repair procedures, systolic anterior motion is prevented with concomitant septal myectomy through the mitral valve orifice. Technically, the exposure of the bulging subaortic septum is traditionally done with detachment of the anterior mitral leaflet from its annulus, leaving a 2-mm rim of leaflet attached to the annulus. The leaflet is then sutured after myectomy. As an alternative technique in robotic surgery, the exposure of the subaortic septum is feasible without anterior leaflet incision with the use of dynamic atrial retractor in mitral repair procedures. Here, we present a patient who underwent concomitant robotic mitral valve repair with posterior chordal implantation, ring annuloplasty, and septal myectomy without anterior leaflet incision using the da Vinci surgical system.