A case series of patients with left ventricular assist devices and concomitant mechanical heart valves.

Mechanical heart valves left in situ at the time of left ventricular assist device (LVAD) implantation are thought to potentially increase the risk of thromboembolism. Recommendations exist to replace dysfunctional mechanical mitral valves and any mechanical aortic valves at the time of LVAD implantation. Due to potential increases in cardiopulmonary bypass time and associated comorbidities with valve replacement, leaving a functional mechanical valve in place at LVAD implantation has been suggested to be a safe option. We retrospectively reviewed all patients with prior mechanical mitral or aortic valves undergoing LVAD implantation at our center between 2012 and 2017. Echocardiograms were read by a single cardiologist to assess for mechanical valve dysfunction. We identified 15 patients. Five patients had major bleeding requiring transfusion. On follow-up, 2 patients had hemorrhagic stroke and 2 had transient ischemic attach/ischemic stroke. In addition, 2 patients had LVAD thrombosis and 2 patients had LVAD driveline malfunction. Mild mechanical valve regurgitation was identified on follow-up echocardiograms of 2 patients. Rate of complications in patients with mechanical valves undergoing LVAD implantation was comparable to that reported for the general LVAD population. Leaving a functional mechanical valve in place at the time of LVAD implantation could be a reasonable alternative to valve replacement. More data are required to further guide patient care in these individuals.

The neutrophil to lymphocyte ratio in patients supported with extracorporeal membrane oxygenation.

INTRODUCTION: The neutrophil to lymphocyte ratio (NLR) has proven to be a robust predictor of mortality in a wide range of cardiovascular diseases. This study investigated the predictive value of the NLR in patients supported by extracorporeal membrane oxygenation (ECMO) systems. METHODS: This study included 107 patients who underwent ECMO implantation for cardiogenic shock. Median preoperative NLR was used to divide the cohort, with Group 1 NLR <14.2 and Group 2 with NLR ≥14.2. Survival, the primary outcome, was compared between groups. RESULTS: The study cohort was composed of 64 (60%) males with an average age 53.1 ± 14.9 years. Patients in Group 1 had an average NLR of 7.5 ± 3.5 compared to 27.1 ± 19.9 in Group 2. Additionally, those in Group 2 had significantly higher preoperative blood urea nitrogen (BUN) and age. Survival analysis indicated a thirty-day survival of 56.2%, with significantly worsened mortality in patients with NLR greater than 14.2, p=0.047. DISCUSSION: Our study shows the NLR has prognostic value in patients undergoing ECMO implantation. Leukocytes are known contributors to myocardial damage and neutrophil infiltration is associated with damage caused by myocardial ischemia.

Administration of cardiac stem cells in patients with ischemic cardiomyopathy: the SCIPIO trial: surgical aspects and interim analysis of myocardial function and viability by magnetic resonance.

BACKGROUND: SCIPIO is a first-in-human, phase 1, randomized, open-label trial of autologous c-kit(+) cardiac stem cells (CSCs) in patients with heart failure of ischemic etiology undergoing coronary artery bypass grafting (CABG). In the present study, we report the surgical aspects and interim cardiac magnetic resonance (CMR) results. METHODS AND RESULTS: A total of 33 patients (20 CSC-treated and 13 control subjects) met final eligibility criteria and were enrolled in SCIPIO. CSCs were isolated from the right atrial appendage harvested and processed during surgery. Harvesting did not affect cardiopulmonary bypass, cross-clamp, or surgical times. In CSC-treated patients, CMR showed a marked increase in both LVEF (from 27.5 ± 1.6% to 35.1 ± 2.4% [P=0.004, n=8] and 41.2 ± 4.5% [P=0.013, n=5] at 4 and 12 months after CSC infusion, respectively) and regional EF in the CSC-infused territory. Infarct size (late gadolinium enhancement) decreased after CSC infusion (by manual delineation: -6.9 ± 1.5 g [-22.7%] at 4 months [P=0.002, n=9] and -9.8 ± 3.5 g [-30.2%] at 12 months [P=0.039, n=6]). LV nonviable mass decreased even more (-11.9 ± 2.5 g [-49.7%] at 4 months [P=0.001] and -14.7 ± 3.9 g [-58.6%] at 12 months [P=0.013]), whereas LV viable mass increased (+11.6 ± 5.1 g at 4 months after CSC infusion [P=0.055] and +31.5 ± 11.0 g at 12 months [P=0.035]). CONCLUSIONS: Isolation of CSCs from cardiac tissue obtained in the operating room is feasible and does not alter practices during CABG surgery. CMR shows that CSC infusion produces a striking improvement in both global and regional LV function, a reduction in infarct size, and an increase in viable tissue that persist at least 1 year and are consistent with cardiac regeneration. CLINICAL TRIAL REGISTRATION: This study is registered with clinicaltrials.gov, trial number NCT00474461.

Outcomes Following Left Ventricular Assist Device Exchange: Focus on the Impacts of Device Infection.

Hemodynamic support with continuous-flow left ventricular assist device (CF-LVAD) therapy has proven a reliable treatment for advanced heart failure. Although modern LVADs are highly durable, device failure and infection can be resolved with surgical exchange of pump components. In this study, we investigated the incidence and outcomes of LVAD exchange with the HeartMate II and HeartWare HVAD. Data were obtained from 677 patients who underwent CF-LVAD implantation between 2005 and 2016. Patients who underwent a device exchanged were included. The primary outcomes were length of hospital stay and mortality. Of the 677 patients included in this study, 72 (10.6%) required LVAD exchange. Thirty-day and 1-year mortality rates were comparable to primary LVAD implantation: 4.3% vs. 3.49%, p = 0.727 and 20.3% vs. 20.7%, p = 0.989, respectively. Thirty-one patients (4.5%) underwent exchange with ongoing infection. Kaplan-Meier analysis indicated significant differences in survival between groups based on indication for exchange. Patients who underwent exchange after more than 150 days of active infection suffered worse postexchange survival than those who underwent exchanged earlier (P = 0.007). While exchange was required only in 10.6% of patients undergoing LVAD implantation, our results show device exchange may be executed safely and effectively, with long-term outcomes similar to primary LVAD implantation. The indication for device exchange impacts postexchange outcomes, and those exchanged with LVAD infection tend to fare worse than those exchanged for device malfunction or thrombus. Patients who are exchanged with active infection have better postoperative survival if the exchange is performed expeditiously after medical management has failed.

Outcomes of pre- heart transplantation desensitization in a series of highly sensitized patients bridged with left ventricular assist devices.

Desensitization therapy for heart transplantation (HT) candidates can shorten transplant wait times and broaden the donor pool. Specific evidence-based recommendations on both protocols and indications are lacking. We retrospectively assessed left ventricular assist devices-bridged candidates who received pre-HT desensitization therapy. The therapeutic protocol consisted of intravenous immunoglobulin and rituximab followed by bortezomib and plasmapheresis if an insufficient response was achieved. Desensitization was attempted in 10 patients; only 7 tolerated therapy and underwent transplant. For those patients, median decrease in unacceptable calculated panel reactive antibody was 11%; there was no significant decrease for 3 patients. Post-desensitization adverse events were observed in all patients which included coagulopathy, bone marrow suppression, and infection. Median time to first infection was 16 days. One patient had clinically significant rejection and 3 patients had uptrending donor-specific antibodies. Decisions to proceed with desensitization should be individualized understanding potential risks and benefits.

Venoarterial extracorporeal membrane oxygenation use in staged combined heart-kidney transplant.

Outside of heart and lung transplantation, only few cases have been reported describing venoarterial extracorporeal membrane oxygenation (VA-ECMO) use in solid organ transplantation. We present a case of a staged combined heart-kidney transplant in which VA-ECMO was utilized after a complicated orthotopic heart transplantation to successfully complete the subsequent renal transplantation.

Postoperative B-Type Natriuretic Peptide as Predictor for Postoperative Outcomes in Patients Implanted With Left Ventricular Assist Devices.

B-type natriuretic peptide (BNP) is a cardiac neurohormone known to correlate with left ventricular (LV) dilation, decreased contractility, and increased stiffness. Consequently, BNP has been used as a prognostic tool to assess the degree of LV unloading for patients supported by continuous-flow LV assist devices (LVADs). We assessed the prognostic value of changes in BNP in the 2 weeks after LVAD implantation. This retrospective study analyzed laboratory findings and outcomes of 189 LVAD patients. Patients were separated into two groups based on whether serum BNP levels had improved from preoperative levels by postoperative day 14. Group 1 had improvement in BNP levels, whereas group 2 had no improvement or worsening in BNP. There were no significant differences between the groups in age, gender, race, body mass index, or comorbidities. Group 1 had preoperative BNP 1,125 ± 1,078.3 pg/dl and postoperative BNP 440.2 ± 267.7 pg/dl (preoperative minus postoperative [ΔBNP] = -693.09 ± 942.4 pg/dl), whereas group 2 had preoperative BNP 346.0 ± 309.1 pg/dl and postoperative BNP 631.57 ± 483.4 pg/dl (ΔBNP = 289.32 ± 329.7 pg/dl). Postoperative survival in group 2 was significantly worse than in group 1. Rates of right ventricular failure (RVF) were significantly higher in group 2 (group 1: 39%, group 2: 52.7%; p = 0.01). In most patients implanted with a LVAD, BNP improves significantly in the postoperative period as the LV is unloaded. Our results indicate that lack of improvement in postoperative BNP is associated with longer length of stay, increased rates of RVF, and is an independent risk factor for reduced postoperative survival.

Improved Nutrition Status in Patients With Advanced Heart Failure Implanted With a Left Ventricular Assist Device.

BACKGROUND: Left ventricular assist device (LVAD) implantation for advanced heart failure is known to improve survival, functional capacity, and quality of life. Most patients implanted with LVADs suffer from moderate to severe malnutrition and deconditioning due to their advanced disease. The Mini Nutritional Assessment (MNA) and the short form of the survey (MNA-SF) are 2 well-validated clinical tools, previously used to assess patient nutrition status in numerous conditions. Earlier work has demonstrated that low nutrition scores can independently predict mortality in the LVAD population. This study explored changes in MNA scores and other clinical markers following LVAD. METHODS: This retrospective study included 74 patients implanted with LVADs between 2012 and 2017. MNA or MNA-SF along with other clinical data and nutrition indices were assessed during the preoperative workup and reassessed on average 423.9 days post LVAD. Paired-samples t-tests were used to evaluate any changes. RESULTS: Despite an average body mass index of 30.8, 28.3% of patients were classified by MNA as malnourished, and 58.5% were considered at risk prior to LVAD implantation. Post LVAD implantation, MNA scores improved from an average of 19.2-23.0 (P < 0.001), with now only 3.8% classified as malnourished and 45.3% classified as at risk. MNA-SF and prognostic nutritional index also improved significantly. CONCLUSIONS: This study indicates that LVAD implantation is associated with a long-term improvement in nutrition status when compared with the preoperative heart failure state.

Risk stratification with longitudinal neutrophil to lymphocyte ratio assessment after left ventricular assist device implantation.

INTRODUCTION: Inflammatory processes are well-characterized risk factors in cardiovascular disease including advanced heart failure. Previous studies have utilized individual white cell subtypes in risk analysis, and a recent study has focused on the efficacy of the neutrophil-to-lymphocyte ratio in evaluating negative outcomes following left ventricular assist device implantation. To investigate the interaction between the left ventricular assist device and white cell counts, we assessed longitudinal changes in neutrophil-to-lymphocyte ratio following left ventricular assist device implantation. METHODS: This retrospective study included 100 patients who underwent left ventricular assist device implantation between 2012 and 2013. The neutrophil-to-lymphocyte ratio was calculated prior to left ventricular assist device implantation, daily for the first 30 postoperative days, and at the first two postoperative outpatient visits. Preoperative demographic and clinical data were collected for all patients. RESULTS: The mean neutrophil-to-lymphocyte ratio immediately before left ventricular assist device implantation was 5.2 ± 4.9. After surgery, the neutrophil-to-lymphocyte ratio decreased asymptotically, from a peak of 29.2 on postoperative day 1 to 4.1 at the second outpatient visit ( p < 0.001). Lack of improvement in the neutrophil-to-lymphocyte ratio at postoperative day 10 was associated with increased length of stay, right heart failure, and a trend toward worsened survival. CONCLUSION: Our results indicate a significant inflammatory response to implantation of the left ventricular assist device, a known effect. The magnitude of this response may be effectively and easily monitored over time using the neutrophil-to-lymphocyte ratio. In general, approximately 30 days is required for the neutrophil-to-lymphocyte ratio to return to preoperative levels. After several months, the neutrophil-to-lymphocyte ratio improves to below preoperative levels. It is possible that this reduction reflects the reversal of various heart failure-mediated inflammatory processes following left ventricular assist device implantation.

The impact of extreme obesity on outcomes after left ventricular assist device implantation.

BACKGROUND: The association between extreme body mass index (BMI) and outcomes in left ventricular assist device (LVAD) patients has not been well established. With the commercial use of LVADs a larger number of patients with a BMI >40 have undergone device implantation. The purpose of this study was to evaluate the short and long-term outcomes of LVAD patients with extreme obesity. METHODS: A retrospective review of all patients (n=383) at our center who received a LVAD as primary implant between 2005-2015 was performed. Demographics, preoperative laboratory values, and postoperative outcomes were analyzed. Patients were divided into three groups based on BMI (kg/m2) classification (group 1: ≤25; group 2: 25 to 35; group 3: ≥35) and compared using one-way analysis of variance (ANOVA), Kruskal-Wallis and Chi-squared analysis as appropriate. RESULTS: Comparison of postoperative outcomes demonstrated an increased risk of respiratory failure and right ventricular (RV) failure in patients with a BMI ≥35 (range, 35-59). Length of stay, sternal infection, driveline/pocket infection, systemic infection, GI-bleeding, and neurological events within the first year of device therapy were not related to BMI. Survival at 30-day, 1- and 2-year was not significantly different among the three groups. The group with the smallest BMI demonstrated an increased risk for re-operative bleeding. CONCLUSIONS: Despite an increased risk of early morbidity in patients with extreme obesity, long term survival was not significantly different between the BMI groups. Careful consideration is recommended when evaluating patients with an excessive BMI for LVAD therapy although it should not be a contraindication for device placement.

Embol-X intra-aortic filtration system: capturing particulate emboli in the cardiac surgery patient.

We sought to evaluate the effectiveness of using an intra-aortic filtration system for the prevention of particulate emboli transport and the minimization of significant postoperative complications associated with particulate emboli. Between October of 2000 and October 2001, a total of 146 patients were enrolled at Advocate Christ Medical Center as part of the multi-institutional randomized trial (1289 patients at 22 centers). A total of 74 patients (51%) received the Embol-X intra-aortic filter and 72 patients (49%) were enrolled in the control group. Patients were evaluated for neurological deficit, myocardial infarction, renal insufficiency/failure, limb ischemia, and death at 12-hour, 24-hour, 72-hour, 7-day, and 30-day postoperative intervals. All filters received histological examination for particulate matter. Particulate matter was isolated in 70 (94.5%) of the filters successfully deployed. There was no statistically significant difference in the device related events between the filter and conventional cannulation groups (9/74 = 12.1% vs. 7/72 = 9.7%). Although not clinically evident, the primary event for both groups was ascending aortic intimal tears. There was one death in each of the groups not related to the filter or cannula used. The use of the Embol-X intra-aortic filter system has proven to be a safe and effective means to reduce the introduction of particulate emboli into the systemic circulation. Clearly, the reduction of particulate matter by as much as 95% justifies its use in cardiac surgery patients identified with an increased pre-operative embolic risk.

Minimally invasive mitral valve repair using the da Vinci robotic system.

BACKGROUND: Minimally invasive mitral valve repair with a shortened hospital stay and quick return to an active lifestyle is the ultimate goal for robotically assisted surgery. We evaluated our da Vinci robotically assisted mitral valve repair experience toward achieving this goal. METHODS: All procedures were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Two ports and a 4-cm intercostal incision in the right chest were used for access. All patients had a ring annuloplasty, and all but 1 had a posterior leaflet resection. The entire repair and all knot tying were performed robotically. RESULTS: Between October 2001 and October 2002, 25 patients (18 men) underwent robotic mitral valve repair. The mean age was 56 years (range, 37 to 81 years). There were no incisional conversions, deaths, strokes, or reoperations for bleeding. Twenty-one (84%) of 25 patients were extubated in the operating room. Overall mean study times were as follows: procedure, 199.7 minutes (range, 140 to 287 minutes); cardiopulmonary bypass, 126.6 minutes (range, 89 to 186 minutes); and cross-clamp, 87.7 minutes (range, 58 to 143 minutes). Eight (32%) patients were discharged home in less than 24 hours, with an average length of stay of 2.7 days. Comparing the first 10 patients to the last 15 there was a significant reduction of times: total operating room time, 318.5 versus 275.1 minutes; cross-clamp, 97.6 versus 81.1 minutes; leaflet resection or repair, 26.2 versus 15.6 minutes; annuloplasty ring, 31.9 versus 24.8 minutes; and length of stay, from 4.2 days to 1.67 days. Five patients had postoperative atrial fibrillation. Two (8%) patients ultimately required mitral valve replacement for recurrent mitral insufficiency. CONCLUSIONS: Mitral valve repair can be successfully performed with the da Vinci robotic system. Long-term follow-up is needed to determine the durability of the repair compared with a standard sternotomy approach.

Prospective clinical study of a novel left atrial appendage occlusion device.

PURPOSE: This Food and Drug Administration-approved investigational device exempt trial assessed the safety and efficacy of a novel device for external left atrial appendage (LAA) exclusion. DESCRIPTION: Delivery tool and implant consisting of connectors imbedded in a compliant, soft silicone applied to the base of the LAA flush with the external wall was assessed. EVALUATION: Patients in this prospective, multicenter trial were undergoing elective, nonendoscopic cardiac operations. A core laboratory independently assessed all intraprocedural and 90-day transesophageal echocardiograms. Sixty patients (37 men), aged 33 to 86 years, enrolled. The mean LAA application time was 27 seconds. Transesophageal echocardiograms at 90 days were available in 54 patients, and no leaks were detected. The residual LAA cavity exceeded 6 mm in 5 patients. One delivery device failed to close, and an adjunctive suture was required to complete LAA exclusion. One patient required adjunct sutures at a small tear site related to manual manipulation after fastener application. CONCLUSIONS: The study demonstrated safety and efficacy of this LAA exclusion device, offering an alternative to manual suturing or staples with or without reinforcement.

Platelet activation in heart failure patients supported by the HeartMate II ventricular assist device.

OBJECTIVE: Thromboembolic events have been observed in heart failure (HF) patients supported by long-term mechanical circulatory support (MCS) devices. It has been hypothesized that these adverse events may be the result of platelet activation associated with high rotational speeds common to axial flow pumps. In this study, markers of platelet activation were investigated in HF patients supported by a HeartMate II left ventricular assist device (LVAD). METHODS: The study group consisted of 34 HF patients supported by a HeartMate II axial flow LVAD implanted for destination therapy (DT). This patient population was 94% male (31 M, 3 F), supported by LVAD for 30 to 723 days (average 268 days), and with an anticoagulation regimen of Coumadin (0-8 mg daily dose) and aspirin (0-325 mg daily dose). Platelet adhesion markers (soluble P-selectin and solube CD40 ligand), platelet count (PC), hematocrit (Hct), and creatinine (Cr) were measured. RESULTS: The soluble P-selectin marker was within normal platelet activity limits for all end points. The soluble CD40 ligand marker indicated platelet inactivity for all end points. Despite high shear stresses associated with a high-speed axial flow pump, the HeartMate II had no discernable effect on platelet activation. Current clinical doses of aspirin also appear to have little effect on platelet activation. Platelet count, hematocrit, and creatinine were normal in these patients over duration of support. CONCLUSIONS: There were no discernable changes in platelet activation markers soluble P-selectin and soluble CD40 ligand in HF patients support by HeartMate II LVAD independently of length of support, anti-platelet, and anti-coagulation regimens.

HeartWare miniature axial-flow ventricular assist device: design and initial feasibility test.

Pulsatile ventricular assist devices have successfully provided circulatory support for many patients throughout the past quarter century; however, persistent complications have hindered expanded clinical application of this technology. Although the use of smaller, continuous-flow ventricular assist device pumps has reduced the frequency and severity of some adverse events, design enhancement may further improve outcomes for patients who require long-term left ventricular support. One new product, the HeartWare, Inc., miniature ventricular assist device, features a wide-bladed rotor design in an axial-flow pump with a strong, passively suspended magnetic rotor. The operating range of 16,000 to 28,000 rpm can provide up to 10 L/min of flow. The wide blades portend minimal cellular trauma.This new device has not yet been approved for use in human beings. As a test, we implanted it in a calf, and we continuously monitored the device's performance and the hemodynamic results over 30 days. No mechanical failure occurred, and no thrombi were noted upon explantation of the device. The animal's circulation was stable during the test period, and no end-organ abnormalities were found upon autopsy. The potential benefits of this miniature ventricular assist device are its increased availability to a broader patient population, a lower risk of infection, simplified implantation procedures, and improved durability. Further in vivo testing is planned. Herein, we discuss the unique design of the HeartWare miniature ventricular assist device, our feasibility study of its performance, and the possibilities for its use in human beings.

Reducing the effects of the systemic inflammatory response to cardiopulmonary bypass: can single dose steroids blunt systemic inflammatory response syndrome?

The use of cardiopulmonary bypass (CPB) is associated with the development of a significant systemic inflammatory response syndrome (SIRS) which can affect patient outcomes. Multiple pathways are involved in initiating and maintaining SIRS. We studied whether a single dose of steroids (dexamethasone) after the induction of anesthesia could blunt the SIRS from CPB. A prospective, randomized, double-blinded, placebo control trial of 28 patients (13 study vs. 15 control). The study group received 100 mg of dexamethasone whereas the control group received sterile saline. Inclusion criteria were the following: elective coronary artery bypass grafting, less than 80 years old, normal ejection fraction, no acute myocardial infarction. Serum levels of C3a, interleukin (IL)-6, and plasma norepinephrine (PNE) were measured after intubation, 30 minutes after initiation of CPB, 24 and 72 hours after termination of bypass. The study group demonstrated significantly lower levels of IL-6 (p = 0.0005) at 24 hours and PNE (p = 0.05) at 72 hours post-CPB. There were no differences in the C3a levels between the groups. No infections occurred in either group. A single dose of dexamethasone reduces IL-6 and PNE levels associated with CPB. Despite the significant reductions in IL-6 and PNE, there was no effect on clinical outcomes. Additional studies are needed to demonstrate a clinically significant effect on patient outcomes.

Prospective study on cardiopulmonary bypass prime reduction and its effect on intraoperative blood product and hemoconcentrator use.

PURPOSE: Evaluate the feasibility and clinical significance of crystalloid prime reduction during the initiation of cardiopulmonary bypass (CPB) using a modified bridge on the cardioplegia delivery system. METHODS: Prospective trial of crystalloid prime reduction using a standard Duraflow-coated CPB circuit and Vanguard 2:1 cardio plegia delivery system. Standard prime volume was 1500 cc of Plasmalyte. Prime was reduced via the bridge in the cardioplegia system during initiation of CPB. Packed red blood cells (PRBC) were transfused for hematocrit (Hct) less than 24% while rewarming. A hemoconcentrator was used if the patient's circulating blood volume exceeded 150% of calculated. All data were prospectively collected. RESULTS: Two hundred and twenty-two consecutive patients undergoing cardiac surgery utilizing CPB were evaluated. There were 107 patients with normal prime volume (NPV) and 115 patients with reduced prime volume (RPV). There was no significant difference in sex, mean age, weight, body surface area (BSA), pre-op Hct, procedure time or procedure between the two groups. There was no difference in total crystalloids infused by the anesthetists (average NPV 1205 cc versus RPV 1148 cc). The average RPV was 622 cc (range 400-1100 cc) or a 59% reduction. Post-op Hct revealed no difference (NPV 28% versus RPV 29%). There was a 24% reduction in patients requiring PRBC (NPV n=23 versus RPV n=18). The use of hemoconcentrators was reduced by 49% (NPV n=18 versus RPV n =11). The average urine output for both groups exceeded 100 cc/hour while on CPB. CONCLUSION: Using a modified cardioplegia delivery system is a safe and effective method of CPB prime reduction. A RPV resulted in fewer patients requiring PRBC transfusions and fewer hemoconcentrators used. Based on our experience, we would recommend attempting to reduce prime volume in all patients undergoing CPB.

Peripheral cardiopulmonary bypass with modified assisted venous drainage and transthoracic aortic crossclamp: optimal management for robotic mitral valve repair.

The purpose of this study was to evaluate peripheral cardiopulmonary bypass (CPB) with modified assisted venous drainage (MAVD) and transthoracic aortic cross-clamping to maintain a bloodless surgical field, adequate myocardial protection, systemic flow and pressure during robotic surgical repair of the mitral valve. Peripheral CPB was established with a standard Duraflo-coated closed circuit with femoral arterial and venous cannulation. An additional 17 Fr wire-bound cannula was inserted into the right internal jugular vein and drainage rates of 200-400 mL/min were regulated using a separate roller-head pump. A transthoracic aortic crossclamp with antegrade cardioplegia was used for myocardial protection. Mitral valve (MV) repair was then performed through two 1-cm ports for the robotic arms and a 4-cm intercostal incision for the camera and passing suture. From October 2001 to October 2002, 25 patients underwent robotic MV repair. Average surgical times include leaflet resection and repair, 20 min, and insertion of annuloplasty ring, 28 min; average perfusion times, crossclamp 88 min and total bypass time of 126 min. There were no incisional conversions, no reoperations for bleeding and no deaths, strokes or perioperative myocardial infarctions. Twenty-one (84%) patients were extubated in the operating room. Average LOS was 2.7 days with eight (32%) patients discharged home in less than 24 hours. In conclusion, peripheral CPB with gravity drainage of the lower body and MAVD of the upper body allow safe and effective support during robotically assisted minimally invasive MV repair. This approach may be applied to other forms of minimally invasive cardiac surgery that requires CPB.