Systematic reviews of minimally invasive aortic valve surgery showed certain advantages over conventional surgery. New trends were introduced in aortic arch surgery. The aim of our study was to compare the results of conventional aortic arch replacement with minimally invasive technique (MIT). The sample comprised a total of 258 patients undergoing aortic arch surgery from 2009 to 2018 at our center. Minimally invasive surgical approach included J-ministernotomy and peripheral cannulation (right subclavian artery and femoral vein) and was performed in 21 (8.2%) patients; of them, 10 (47.6%) patients underwent frozen elephant trunk procedure, 2 (9.5%) elephant trunk procedure, and 9 (42.9%) hemiarch procedure ( Figure PC1-1 ). Propensity score matching produced 21 (ministernotomy vs. full sternotomy [FS]) well-matched pairs to correct for differences in baseline characteristics. Primary endpoints were in-hospital mortality, blood loss, complications, intensive care unit stay, hospital stay, and 30-day survival; secondary endpoints were 1-year follow-up survival, stroke, reinterventions, and reoperations. A p-value 2DS2-VASc scoring. All adult cardiac surgical patients who underwent left atrial appendage exclusion at our institution were retrospectively studied. Baseline clinical data including age, type of surgery, approach, and CHA2DS2-VASc score were evaluated. The incidence of stroke was calculated at the most recent follow-up. The observed stroke rate was compared to the expected stroke rate base on CHA2DS2-VASc scoring. Between September 2011 and June 2017, 241 patients underwent left atrial appendage exclusion as a stand-alone procedure or with other concomitant cardiac surgical procedures. Two hundred thirty patients (95%) were available for follow-up. One hundred sixty-eight patients (73%) of these patients had the procedure performed minimally invasively either by a right minithoracotomy, upper sternotomy, or via a video-assisted approach. Median age was 72 (range 43–89 years), percent male was 68, median baseline CHA2DS2-VASc was 3. One hundred ten patients (48%) were on oral anticoagulation at the time of follow-up. At an average of 21 months follow-up, the incidence of embolic stroke was 0.9% vs. an expected stroke rate of 5.6% based on their CHA2DS2-VASc (p < 0.05). Various minimally invasive approaches are feasible for left atrial appendage exclusion. These approaches to left atrial appendage exclusion are associated with a reduction in stroke incidence. Randomized, prospective trials may help clarify the benefits of surgical left atrial appendage exclusion. To evaluate early results in prospective randomized controlled trial (RCT) prophylactic pulmonary vein ablation (PULVAB) for coronary artery bypass grafting (CABG). The RCT including 96 patients with coronary artery disease was conducted. There were 3 groups: group 1 (n = 34) was the controlled group of the conventional CABG without ablation. In group 2 (n = 29), conventional CABG was combined with prophylactic pulmonary bipolar radiofrequency ablation (RFA). In group 3, conventional CABG and prophylactic PULVAB were added with the administration of amiodarone in the postoperative period. Concomitant ablation did not lead to the increase of the operation’s main stages’ length. The time of operation was 251 ± 37.7 minutes in group 1, 250.4 ± 42.5 minutes in group 2, and 244.2 ± 29 minutes in group 3 (p = 0.114) and did not differ in the cardiopulmonary bypass time (88.6 ± 19.2; 92 ± 18.4 and 84.8 ± 17.3 minutes; p = 0.08). In-hospital mortality was 0 among the studied groups. Wound complications, bleeding, perioperative myocardial infarction, and stroke were not also noted. Postoperative atrial fibrillation (AF) was registered in 11 (32.4%) patients from the 1st group, in 6 (20.7%) from the 2nd group, and in 2 (6.1%) from the 3rd group. There was no significant difference between groups 1 and 2 (p = 0.298) and also between groups 2 and 3 (p = 0.086). Statistically significant difference was registered between patients from groups 1 and 3 (p = 0.0065), which indicates the effectiveness of the combined methods for preventing AF. AF in 91% of patients occurred at 2–4 days of the postoperative period. Sinus rhythm at discharge was recorded in 97.1% (group 1), 96.7% (group 2), and 97% (group 3), respectively (p = 0.293). There was a tendency to a decrease in the frequency of AF in patients undergoing preventive bipolar RFA of the pulmonary veins. The combination of prophylactic bipolar RFA and amiodarone usage revealed significantly positive results in the postoperative AF prevention. Cryoenergy, together with radiofrequency energy, is the most used method of lesion formation in patients undergoing surgical ablation of atrial fibrillation. Despite its frequent use, the clinical effect of cryoenergy use in endocardial and epicardial approach is unknown. The aim of this study was to compare the effect of different cryoenergy applications on the postoperative incidence of sinus rhythm and the completeness of the lesions performed. A total of 55 patients underwent surgical ablation of atrial fibrillation as part of another cardiac surgery procedure (myocardial revascularization, valve surgery, and combined procedure). The standard protocol of surgical ablation contains isolation of the pulmonary veins and creation of box lesion by cryoenergy under various conditions – epicardially on extracorporeal circulation and cardiac arrest, epicardially on extracorporeal circulation on beating heart, and endocardially. In the postoperative period, patients were invited to electrophysiological examination, where the completeness of surgical ablation lesions was evaluated and completed by catheter ablation if necessary. Twenty-four patients underwent epicardial ablation on the arrested heart (group 1), 12 patients underwent epicardial ablation on the beating heart (group 2), and 19 patients underwent endocardial ablation (group 3). The interval between cardiac surgery and electrophysiological examination was 144 ± 138 days vs. 178 ± 84 days vs. 102 ± 76 days. In the electrophysiological examination, the sinus rhythm was presented in 71% vs. 83% vs. 89% of patients. The completeness of pulmonary vein isolation was confirmed in 31% vs. 25% vs. 95% of patients, complete box lesions then in 15% vs. 0% vs. 79% of patients. Despite the similar clinical effect of surgical ablation in all three approaches, the most morphologically effective use of cryoenergy is endocardial ablation. This approach has a very good result. Our finding further supports the endocardial use of cryoenergy during surgical ablation of atrial fibrillation. We evaluated the outcomes of minimally invasive box-lesion ablation for the treatment of stand-alone atrial fibrillation (AFiB) in our institution. Prospective analysis of 65 patients (mean age of 62.7 years) who were scheduled for bilateral thoracoscopic ablation of either symptomatic paroxysmal (n = 14; 21.5%) or long-standing persistent AFiB (n = 51; 78.5%) from January 2014 to December 2017. The box-lesion procedure comprised bilateral pulmonary veins and left atrial posterior wall ablation using irrigated bipolar radiofrequency. No severe ablation-related complications were observed (bleeding, myocardial infarction, stroke, or death) during in-hospital stay. During 1-year follow-up, sinus rhythm was maintained in 44 patients (67.7%) with no need of antiarrhythmic drug therapy in 42 patients (64.6%). Fourteen patients out of 21 (21.5%) who suffered from after-procedure AFib recurrence underwent endocardial electrophysiological mapping. Completeness of conduction block, which did not require additional catheter ablation, was confirmed in only 4 of those patients (28.6%). Minimally invasive thoracoscopic box-lesion ablation is considered to be a safe and an effective method of stand-alone AFiB treatment. High risk of box-lesion incompleteness in patients with AFiB recurrence in our cohort justifies routine implementation of staged hybrid approach for all patients considering undergoing this procedure. Supported by MH CZ - DRO (FNOl, 00098892). Advantages of del Nido cardioplegia (DNC) over Buckberg cardioplegia (BC) include longer redosing intervals and lower cardioplegia volume delivered. While totally endoscopic robotic cases may derive benefit from having fewer interruptions for cardioplegia administration, adequacy of myocardial protection remains unknown. We reviewed case-matched outcomes of DNC vs. BC in intracardiac robotic patients. From 5/11 to 4/18, 601 consecutive patients underwent robotic intracardiac surgery requiring cardioplegia at a single institution using the daVinciXi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Operations were performed via right chest ports without minithoracotomy. After an initial experience with BC (n = 73), we transitioned to DNC in 5/13. We case-matched DNC and BC groups based on age, gender, cross-clamp time, and left ventricular ejection fraction resulting in 66 patients in each group. Parametric and nonparametric tests were used to analyze differences between the case-matched groups. Statistical analysis was performed using SPSS 25 (IBM Corp, Armonk, NY, USA). Mitral repairs accounted for 95% (125/132) of our case-matched operations. Median bypass and cross-clamp time in DNC patients were 115 and 80 minutes, respectively. DNC was associated with less frequent redosing (median number of injections 2 vs. 4, p < 0.001), greater rates of single-injection cardioplegia administration (22.7% vs. 7.6%, p = 0.027), and less cardioplegia volume delivered (median 2,000 vs. 3,100 ml, p < 0.001) ( Table PC17-1 ). DNC and BC had similar rates of antegrade/retrograde (66.7% vs. 69.7%), antegrade only (30.3% vs. 28.8%), and retrograde only (3.0% vs. 1.5%) cardioplegia delivery (p = 0.817). DNC and BC groups had similar salvaged blood utilization (340 vs. 300 ml, p = 0.080), similar postoperative glucose levels (163 vs. 149, p = 0.069), and similar intraoperative blood product utilization (10.6% vs. 9.1%, p = 1.000). Both DNC and BC patients had similar rates of prolonged postoperative inotropic (13.6% vs. 13.6%, p = 1.000) or vasopressor (16.7% vs. 11.4%, p = 0.583) support. There were no 30-day mortalities in either group. Median hospital length of stay (LOS) was 4 days in both DNC and BC patients (p = 0.627). Table PC17-1. Pre-operative variables, intra-operative variables, and outcomes between case-matched robotic patients who received del Nido cardioplegia (DNC) vs Buckberg cardioplegia(BC) BC: Buckberg cardioplegia; BMI: body mass index; CPB: cardiopulmonary bypass; DNC: del Nido cardioplegia; LVEF: left ventricular ejection fraction; NYHA: New York Health Association; XC: cross-clamp. By minimizing the frequency of redosing, DNC allows fewer interruptions for cardioplegia administration than BC. Utilization of DNC did not compromise patient outcomes compared to BC as evidenced by similar rates of prolonged inotropic and vasopressor support, equivalent hospital LOS, and no 30-day mortalities. In minimally invasive cardiac surgery (MICS), the common femoral artery (CFA) cannulation during cardiopulmonary bypass (CPB) could cause limb ischemia (LI). We hypothesize that lack of or poor collateral circulation via the deep femoral artery (DFA) or side branches may be more significant than the size discrepancy in terms of LI. This study evaluates the risk factors of LI in MICS from the point of view of anatomy of the femoral arteries. We performed a retrospective review of 47 patients who underwent MICS without prosthetic graft conduit for femoral arterial cannulation between January 2014 and August 2017 at our institution. Regional oxygen saturation (rSO2) of both lower extremities was monitored during the operation by INVOS®. The diameters of CFA, superficial femoral artery (SFA), and DFA were measured using preoperative computed tomography. Based on those diameters and the presence or absence of side branches that can have collateral circulation, we divided them into the following 4 anatomical types (type A: DFA > SFA without branch, type B: DFA < SFA with side branch in CFA, type C: DFA < SFA with side branch in bifurcation of SFA and DFA, type D: DFA < SFA without side branch). We used maximum value of postoperative creatine kinase (CKmax) as the index of postoperative LI. To exclude the influence of each muscle mass, CK divided the area of muscles of femoral regions and it is defined as CK/MA. The predictors for LI, including age, sex, body surface area, body mass index, CPB time, the diameter of CFA, SFA, and DFA, remaining lumen size of CFA after the cannulation, the anatomical types of femoral artery, and the baseline and the drop rate from the baseline of rSO2 of lower extremities, were analyzed. No critical LI occurred in 47 patients. In the anatomical type of femoral artery, type A was the most numerous (type A: 27 [57%] legs, type B: 5 [11%] legs, type C: 3 [6%] legs, type D: 12 [26%] legs). In this cohort, the median CKmax was 1973 U/l (1,293–2,894) and the median CK/MA was 15.6 U/l/cm2 (9.9–20.1). In multivariate analysis of CK/MA >20, anatomical type D was the only predictor (odds ratio 7.188; 95% confidence interval: 1.023–50.506, p = 0.0047) and the remaining lumen size of CFA after the cannulation and the drop rate of rSO2 were not predictors. Our result suggested that anatomical type D was a risk factor for LI in MICS. In type D cases, attention should be paid to the choice of the cannulation site. Acute cardiogenic shock is associated with high mortality rates. The Impella device is a microaxial left ventricular assist device that can be inserted through the axillary artery. The purpose of our study is to determine the role of the axillary Impella devices on patients with acute cardiogenic shock. A retrospective chart review was conducted to identify patients who underwent Axillary Impella device placement for acute cardiogenic shock from January 1, 2014 to September 30, 2018 at a single institution. In-patient records were examined to determine the duration of device, length of stay (LOS), postoperative complications, and 30-day in-hospital mortality. A total of 40 patients, who were primarily men (N = 29) with a mean age of 61.2 ± 10.7 years, underwent Axillary Impella placement for cardiogenic shock. The primary reasons for implant were (1) requirement of upgraded support from an Impella CP or intra-aortic balloon pump (IABP) to Impella 5.0, (2) to treat left ventricular (LV) distention for patients on extracorporeal mechanical oxygenation (ECMO), and (3) to provide longer-term support and allow for mobilization of the patients. Twenty-three of the patients had previous devices already in place including a femoral Impella CP device or an IABP and 9 patients were on ECMO support. The duration of the device was 21.05 ± 17 days with the LOS of 40.8 ± 28 days for those patients. Seventeen of the patients went on to additional surgery including (1) Heartmate 3 device placement (N = 6), (2) other cardiac procedures such as surgical revascularization (N = 9), and orthotopic heart transplantation (N = 2). A total of 21 patients of the 40 (52%) died during hospitalization with 7 patients (17%) having complications related to the Impella device. These complications included right arm ischemia or neuropathy (N = 3) and Impella malfunction requiring device replacement (N = 4). The majority of these devices were placed in the right axillary artery (N = 38) vs. the left axillary artery (N = 2). A total of 58% (N = 23) of the study patients had previous mechanical support and 23% (N = 9) were on ECMO demonstrating the severity of disease and accounting for the high mortality. The Axillary Impella device allows for a minimally invasively placed device that is durable with a mean duration of 3 weeks. The Axillary artery Impella 5.0 provides upgraded full cardiac support while allowing for mobilization of the patient. In addition, it treats LV distention in patients on ECMO while avoiding sternotomy. Finally, the Axillary Impella provides time for decision making for additional therapy with either long-term devices or orthotopic heart transplant. Therapy of severe pulmonary embolism (PE) in patients immediately after surgery poses a difficult challenge with regard to bleeding complications. Ultrasound-accelerated thrombolysis (USAT) has proven to be an effective therapy for severe PE using a fraction of conventional lysis doses. In this case series, we present 3 cases with severe PE immediately after surgery treated by ultra-low-dose USAT. Between June and October 2017, 3 patients (2 male, 60 and 61 years old; 1 female, 16 years old) with symptomatic massive PE early after surgery were presented to our interdisciplinary PE response team where ultra-low-dose USAT was decided to be applied due to the extent of PE and previous surgery in all patients. The patients were fitted with 2 EKOS® 12 cm devices (BTG Ltd, Surrey, UK) in each respective pulmonary artery across the occlusive thrombi for 6 hours receiving 1 mg rt-PA/h/catheter. Transthoracic echograms and computed tomography (CT) scans were performed before and within 48 hours of therapy initiation. All 3 patients survived USAT uneventful with minor bleeding receiving a total dose of 12 mg rt-PA per patient. Within the first hours of therapy significant reduction of RV/LV ratio (1.3 ± 0.2 vs. 0.7 ± 0.08, p: 0.043) and mean pulmonary arterial pressure (33.4 ± 6.1 mmHg vs. 21.7 ± 3.2 mmHg, p: 0.021) as well as significant increase of oxygen saturation on room air (O2 sat, 83.6 ± 4.1 vs. 99.3 ± 1.1, p: 0.012) and right ventricular peak systolic strain rate (−1.12 ± 0.07 s−1 vs. −1.37 ± 0.05 s−1, p: 0.011) was observed. Notable reduction of heart rate, systolic pulmonary arterial pressure, and longitudinal peak systolic strain, and an increase in tricuspid annular plane systolic excursion and tricuspid annular systolic velocity were also documented (Table PC20-1). Follow-up CT scans revealed only minor remaining nonobstructive thrombi. Table PC20-1. Table PC20-1. In this case series, ultra-low-dose USAT resulted in nearly complete resolution of thrombus within 6 hours of therapy with very rapid recovery of hemodynamics in these highly symptomatic patients. Thus, ultra-low-dose USAT appears to be a safe and reasonable therapy option for early postoperative PE. Femoral artery perfusion represents a standard cannulation approach in minimally invasive mitral valve surgery, while several limitations due to retrograde aortic perfusion exist. Antegrade arterial flow through the axillary artery has theoretical advantages as compared to the retrograde femoral approach, which have to be confirmed yet in the clinical setting. We aimed to compare the postoperative outcomes of axillary artery perfusion vs. retrograde femoral perfusion in the minimally invasive mitral valve surgery setting. We systematically analyzed the outcomes of 46 consecutive patients who underwent minimally invasive mitral valve surgery between 2016 and 2018 using the arterial cannulation of right axillary artery (group A) due to severe aortic arteriosclerosis. Perioperative outcomes of the study group were compared with a historical control group of retrograde femoral perfusion (group F), which was adjusted for age and gender (n = 46) according to the propensity score matching. Primary endpoint of the study was in-hospital mortality and perioperative cerebrovascular events. Perioperative risk score values were significantly higher in group A compared to group F (EuroSCORE II: 3.99 ± 2.57 vs. 1.67 ± 1.58; p = 0.001; Society of Thoracic Surgery score: 2.19 ± 1.49 vs. 1.31 ± 0.64; p = 0.023). Cardiopulmonary bypass time (group A: 172 ± 46; group F: 178 ± 51 minutes; p = 0.627) and duration of surgery (group A: 260 ± 65; group F: 257 ± 69 minutes; p = 0.870) were comparable in both groups. However, aortic cross-clamp time was significantly shorter in group A as compared to group F (86 ± 20 vs. 111 ± 29 minutes; p < 0.001). There was no perioperative stroke in both study groups. In-hospital mortality was comparable in both groups (p = 0.495). In group A, 1 patient required median sternotomy and central aortic repair due to intraoperative aortic dissection. No major cardiovascular events occurred in group A, despite significantly increased perioperative risk profile. Right axillary artery perfusion is a safe and reproducible technique in an elderly cohort of patients undergoing minimally invasive mitral valve surgery who present with the signs of systemic atherosclerosis. Given the appropriate institutional expertise in minimally invasive mitral valve surgery, high-risk patients with severe arteriosclerosis can be safely treated via the minimally invasive approach using antegrade arterial perfusion. Acute biventricular failure poses a unique challenge due to the morbidity associated with conventional support techniques, such as venoarterial extracorporeal membrane oxygenation (VA ECMO). Recent developments in percutaneously inserted right and left ventricular support devices have made these minimally invasive options useful in acute failure. Biventricular percutaneous support in the adult population for treatment of acute cardiogenic shock has not been reported yet. Here we present our early experience with this technique. A retrospective review of a prospectively collected database was performed for all patients receiving biventricular percutaneous support from March 2018 to December 2018. Inclusion criteria were patients suffering acute cardiogenic shock and who received concomitant percutaneous biventricular support. This support was provided via a right ventricular support device (RVAD) inserted in the right internal jugular vein combined with a left ventricular support device (LVAD) inserted in the right subclavian artery. Primary endpoint was patient survival to device explant. Patient characteristics, pre- and postoperative variables, and short-term outcomes were collected with a focus on patient hemodynamics and device-related complications. Four patients met inclusion criteria age 20–75 (median 59). Etiologies of heart failure included viral cardiomyopathy (n = 1), acute ischemic heart disease (n = 2), and post-cardiotomy biventricular failure (n = 1). Median preoperative cardiac index was 1.8 l/min/m2 (range 1.5–2.6), with a median cardiac output of 3.8 l/min (2.9–6.7). Ejection fraction was 5%–60% on inotropic support, with a median preoperative vasoactive inotrope score (VIS) of 32.1 (18–43.8). Patients normalized their preoperative lactic acidosis after a median of 3 hours and were noted to have a median immediate postoperative reduction in VIS of 12.2 (1–23.1, Figure PC22-1 ) after device implantation. Patients received biventricular support for 5.5 days (range 1–11). Two patients survived to device explant, with no patient suffering device-related stroke, pulmonary emboli, valvular injury, or bleeding requiring reintervention. Figure PC22-1. Vasoactive Inotrope Score Prior and After Implant. VIS: vasoactive inotrope score. Combined percutaneous RVAD and LVAD implantation can successfully be employed as a stand-alone therapy, or as a bridge to further treatment in patients with cardiogenic shock. This novel technique warrants further investigation and refinement, and can potentially offer a rapidly deployed minimally invasive alternative to VA ECMO in select patients. Patients with acute mitral valve regurgitation (MR) presenting with cardiogenic shock have a high risk of mortality. Preoperative stabilization may improve overall patient survival. The purpose of this study is to evaluate the application of the transcatheter mitral valve repair system in patients with acute severe MR and cardiogenic shock. From 2014 to 2018, 6 patients underwent MitraClip placement for acute MR and cardiogenic shock. The median age was 83 years (range 73–89). Five patients (83%) were female. Three patients (50%) had a prior myocardial infarction. Five patients (83%) had severe and 1 patient (17%) had moderate MR prior to MitraClip implantation. Three patients (50%) had ejection fraction below 40% (median 42%, range 28%–65%). Four patients required preoperative left ventricular assist device placement to support their left ventricular function. Transcatheter mitral valve repair system was implanted at a median 6.5 days (range 0–17 days) from admission. Post procedure, 4 patients (66%) had mild MR and 2 (44%) patients had moderate MR. The median duration of ventilatory support was 3.3 days (0–35.8 days). Thirty-day mortality was 33% (2 patients). One patient had mitral valve replacement 6 months after MitraClip implantation for severe recurrent MR. The transcatheter mitral valve repair system may decrease mortality in critically ill patients presenting with acute mitral regurgitation and cardiogenic shock and avoids emergency surgery owing to successful acute stabilization. Myocardial bridges (MBs) are a congenital coronary variant in which contractile myocardium overlies a coronary artery. Patients with hemodynamically significant MBs of the left anterior descending (LAD) coronary artery may present with debilitating angina despite optimal medical therapy. We previously demonstrated that surgical MB unroofing via sternotomy significantly improves symptoms and quality of life. We hypothesized that minimally invasive MB unroofing could achieve similar results. Adult patients (n = 101) who underwent LAD MB unroofing at our institution between November 2011 and December 2018 were included. MBs were characterized by coronary angiography and intravascular ultrasonography. Hemodynamic significance was determined by diastolic fractional flow reserve (dFFR) measured distal to the MB. Surgical unroofing was performed via sternotomy (n = 72, 2011–2018) or left anterior minithoracotomy (n = 29, 2016–2018). The primary outcome was symptom status assessed by Seattle Angina Questionnaire (SAQ) before and 6 months after surgery. Secondary outcomes included surgery duration, length of hospital stay, and incidence of postoperative complications. There were no significant differences in baseline patient characteristics between the groups. Patients were young (sternotomy 45.5 [36.5–58.0] years, mini 54.0 [39.0–57.0] years) and mostly female (sternotomy 58.3%, mini 51.7%). All patients were symptomatic. MB lengths were comparable (sternotomy 2.87 [2.07–4.62] cm, mini 2.84 [2.16–3.60] cm), although dFFR was lower in the mini group (0.59 [0.53–0.68] vs. 0.67 [0.57–0.73], p = 0.036). While all minithoracotomy cases were performed off-pump, 51.4% of sternotomy cases were performed with the heart arrested on cardiopulmonary bypass. The mini group experienced a shorter surgery duration (134 [120–149] minutes vs. 162 [134–216] minutes, p = 0.001) and shorter hospital stay (3 [3–4] days vs. 4 [4–5] days, p = 0.001). There were no occurrences of death, myocardial infarction, or stroke in either group. The mini group experienced no blood transfusions or surgical wound infections, whereas these occurred in 4.2% and 2.8% of sternotomy cases, respectively. SAQ scores improved significantly after mini MB unroofing with regard to physical limitation, anginal stability and frequency, treatment satisfaction, and quality of life ( Figure PC25-1 ). Figure PC25-1. Graphical presentation of preoperative (orange) and 6-month postoperative (blue) seattle Angina Questionnaire scores for patients who underwent minimally invasive myocardial bridge unroofing. Data are presented as median [interquartile range]. Dots indicate median; boxes indicate interquartile range. P-value ® Fluorescence Imaging (Firefly) to assess LITA quality in robot-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). We retrospectively reviewed clinical records and intraoperative video of 30 patients who underwent R-MIDCAB with LITA-left anterior descending (LAD) coronary bypass. All patients had postharvest assessment of LITA blood flow by Firefly with 1 ml (2.5 mg/ml) of indocyanine green injection through a central line. Twenty-seven of the patients were male, mean age was 67.7 ± 10.7 (SD) years. In postharvest assessment performed before transection of the distal LITA, blood flow in LITA was well visualized in 28 patients. In the remaining 2 patients, one had dissection and the other had severe spasm of the LITA. Firefly was also useful for locating LITA and LAD and for assessing blood flow of the graft after anastomosis. Time required for each Firefly assessment was approximately 20 seconds. There were no side-effects or complications due to Firefly intra- and postoperatively. Twenty-six patients had postoperative coronary computed tomography; LITA patency rate was 100% (26/26). Firefly is fast, simple, and effective for locating and assessing flow in LITA and LAD before and after anastomosis in R-MIDCAB. The ideal blood salvaging strategies for off-pump coronary artery bypass graft procedures have not been determined. We developed a new blood salvaging system that uses a cardiotomy suction. The purpose of this study was to examine the efficacy of this novel method. This was a retrospective study involving 100 consecutive patients undergoing off-pump coronary artery bypass grafting from June 2015 to July 2018 in our hospital. In 50 patients, a simple cardiotomy suction system was used (cardiotomy suction group). These individuals were compared with 50 historical cohorts who were treated with the conventional cell saver system (cell saver group). There was no significant difference in the patient’s background. There was no in-hospital mortality in either group. The patients who received a blood transfusion were significantly fewer in the cardiotomy suction group (cardiotomy: 22%; 11/50 vs. cell saver: 44%; 22/50, p = 0.03). The cardiotomy suction group tended to have received fewer transfused red blood cells (cardiotomy: 0.85 ± 2.1 units vs. cell saver: 1.44 ± 2.4 units, p = 0.18). The postoperative serum total protein and albumin levels were significantly higher in the cardiotomy group. As there was concern about kidney injury due to crushed erythrocyte because it had not been removed in the cardiotomy suction group, there was no significant difference about the rate of change in serum creatinine level and the postoperative amount of urine. Our newly developed simple cardiotomy suction system, when compared with the conventional cell saver system, produced similar clinical results and attenuated postoperative hemodilution. Our system may emerge as a preferable alternative for blood salvage during off-pump coronary artery bypass grafting. Figure PC27-1. Minimally invasive approaches for graft procurement are associated with excellent outcomes in terms of morbidity and patients’ discomfort, thus without affecting graft quality, patency rate, and long-term outcomes in patients undergoing coronary artery bypass grafting (CABG) surgery. We aim to extensively describe the technique for endoscopic radial artery (RA) and saphenous vein (SV) harvesting using non-sealed approach for grafts procurement during CABG surgery. All patients scheduled for coronary artery bypass surgery can potentially benefit of an endoscopic approach when the use of RA and/or SV is planned. In this video, endoscopic harvesting of RA and SV was performed by means of nonsealed system. Nonsealed systems do not require active carbon dioxide insufflation; however, CO2 may be used as a visual flush without any occlusive port at the entry point; thus, adoption of a nonsealed approach encompasses any potential drawbacks of active CO2 insufflation. Endoscopic harvesting for RA and SV showed similar macroscopic results when compared to “open” techniques. Microscopically, structural and functional viability of the endothelium and vasoreactivity are preserved after endoscopic harvesting. Detrimental effects were demonstrated on functional and structural properties of the SV and RA and such changes are significantly higher when a “sealed system” approach is used. Minimally invasive techniques demonstrated significant better outcomes in terms of incidence of wound and neurological complications as well as patients’ satisfaction when compared to “open” techniques for graft harvesting. Harvesting-related pain and discomfort, mobility, and sensory disfunction are significantly less relevant after minimally invasive conduit harvesting. In conclusion, increasing evidences support the use of endoscopic approaches for graft procurement and such techniques showed to be safe and effective with comparable results in terms of graft quality and cardiac-related adverse events but a significantly superiority in terms of complications and patients’ satisfaction when compared to open approaches. Post-pericardiotomy syndrome has been reported in 10%–40% of all cardiac surgery patients. In spite of a lower incidence of this syndrome in patients undergoing sternal-sparing surgery, we continue to observe it in our beating-heart totally endoscopic coronary bypass (TECAB) patients. The aim of this study is to evaluate if a 6-day steroid taper after TECAB would decrease the incidence and manifestations of post-pericardiotomy syndrome. This retrospective study evaluated the outcomes of 100 patients undergoing single- and multivessel TECAB from January 2017 to October 2018 in our center. We compared postoperative outcomes of 100 patients who did and did not receive a postoperative steroid taper. STATA software was used to evaluate the effect of steroids on each outcome of interest using multiple linear regression for continuous outcomes and logistic regression for binary outcomes. During the study period, the “steroid group” (n = 50) was given 100 mg of intravenous (IV) hydrocortisone intraoperatively and a 6-day oral methylprednisolone taper starting on postoperative day 1 with 24 mg. The control “non-steroid group” (n = 50) did not receive any postoperative steroids after the initial intraoperative IV dose. The groups were similar with respect to gender, age, number of vessels bypassed, Society of Thoracic Surgery risk, and operative time. Although mean intensive care unit and hospital lengths of stay trended shorter in the “non-steroid” group and the number of patients diagnosed with postoperative pericarditis was lower (1.08 days vs. 1.44 days, p = 0.094, and 2.6 days vs. 3.2 days, p = 0.062, and 2 patients vs. 6 patients, p = 0.099 respectively), none of these outcomes reached statistical significance. Average pain scores and postoperative complications (including atrial fibrillation, pericardial effusion, pleural effusion, stroke, acute renal failure, myocardial infarction, readmission, and mortality) showed no significant differences between the groups. Average chest tube drainage was lower and mean glucose level was higher on the first postoperative day in the “steroid group” (105 ml vs. 205 ml, p = 0.009 and 169 vs. 147, p = 0.007, respectively). In this pilot study of patients undergoing beating-heart TECAB, we found a trend of shorter lengths of stay and a decreased incidence of clinical post-pericardiotomy syndrome when postoperative oral steroids were given. Further larger studies are warranted. Table PC29-1. Table PC29-1. The robotic-assisted minimally invasive coronary artery bypass (MIDCAB) consists of facilitating the endoscopic harvesting of the left internal mammary artery. As many centers are increasingly implanting minimally invasive programs, we sought to evaluate the impact of the learning curve on early outcomes following robotic-assisted MIDCAB. From 2006 to 2018, 236 consecutive robotic-assisted MIDCAB procedures were performed, representing the entire inaugural experience. The cohort was divided into 2 consecutive periods of 118 patients according to the period of surgery (P1 and P2). Efficiency endpoints included surgery and coronary occlusion duration, and safety included mortality and major morbidity. A cumulative sum (CUSUM) analysis was performed for a composite endpoint including early mortality, reintervention for bleeding, prolonged intubation, stroke, myocardial infarction, hemofiltration, and urgent conversion. The expected major complication was set at 10%. There were 2 operative mortalities (0.8%). In terms of safety, there was no difference in the incidence of major complications between the two periods (P1: 13 [11%] and P2: 9 [8%]; p = 0.37). The CUSUM analysis showed that the rate of major complications remained constant during the study period. In terms of efficiency, there was a statistically significant improvement of surgery duration after the first period (P1: 2.5 [1.6–5.5] hours vs. P2: 2.2 [1.6–5.3] hours; p = 0.01). However, the duration of the coronary occlusion was similar across the two study periods (P1: 9.5 ± 4.3 minutes vs. P2: 8.8 ± 2.9 minutes). The median length of hospital was similar between the 2 periods (5 [1–33] days). In conclusion, there is no significant impact of the learning curve on early complications following robotic-assisted MIDCAB. However, surgery duration improves over time. Figure PC30-1. CUSUM: cumulative sum. No-touch (NT) saphenous vein (SV) harvesting preserves the adventitial vaso vasorum, prevents medial ischemia, and is associated with an improved short- and long-term vein graft patency. However, the wound complications after NT-SV harvesting are reported to be more significant than the associated skeletonized technique. The majority of the complications are caused by thermal injury resulting from the use of heat-generating monopolar electrocautery. The superficial inguinal lymph nodes and large lymph vessels accompany the SV anatomically and are prone to damage during the harvesting, which may also be associated with a higher rate of the complications. The electrothermal bipolar vessel sealing device (EBVSD) has been designed to aid in coagulation and dissection with less thermal spread than conventional electrocautery. We introduced EBVSD to NT-SV harvesting thorough mini-incisions, considering the ability of this method to firmly seal the lymphatic vessels. The aim of this study was to clarify whether EBVSD contributed to the feasibility of this minimal NT-SV harvesting. After anesthetic induction, ultrasonography mapping was performed to assess the course and quality of SV. Some surgical instruments have been devised to facilitate with small incisions. Through small incisions made at levels of upper thigh, knee, and ankle, a cordless retractor with a built-in LED light source was inserted to enhance the visualization of the operating field and brightens up the operating field. The SV was harvested with a pedicle of surrounding tissue of about 5 mm attached to the main trunk of the SV using EBVSD. Due to the lack of smooth muscle cells in the wall of lymphatic vessels, and a lack of thrombocytes in lymphatic fluids, it was attempted to seal the surrounding connective tissue together with the lymphatic vessels to reinforce the sealing effect. NT-SV was harvested successfully without any complications through mini-incisions. After insertion of a 15 Fr round silicone drain in the SV harvest site, the skin is closed with running suture with absorbable monofilament suture without postoperative complications. This technique is highly possible and could have certain vessels sealing and improved workability and postoperative outcome. Further research is required to refine technology and techniques. Off-pump myocardial revascularization allows improved short-term results of coronary surgery regarding mortality and neurological outcome. Still, there is limited data about the long-term major adverse cardiac and cerebral events (MACCE) results in large cohort studies with long-term follow-up. This study demonstrates those results of more than 3,000 patients. Between 2006 and 2012, 5,915 patients received an isolated coronary artery bypass grafting procedure in our department. We excluded all patients receiving an emergency or redo procedure and patients operated via left-sided minithoracotomy. Of the remaining 3,217 patients, 2,337 were operated off pump and 880 on pump. All patients were interviewed regarding survival, repeat revascularization, recurrence of angina, and MACCE rate. The perioperative data did not differ between the two groups. During the long-term follow-up a significant advantage for the off-pump coronary bypass (OPCAB) technique was found regarding cerebrovascular stroke and survival (Table PC32-1). Table PC32-1. Table PC32-1. Although the OPCAB technique is described as more demanding for the surgeon compared to the on-pump revascularization, patients operated off-pump show a significant benefit regarding long-term survival and interestingly late-onset of cerebrovascular stroke. Outcomes of the Florida Sleeve (FS) procedure in patients with bicuspid aortic valve (BAV) have not been reported before. We compared outcomes of the FS procedure in patients with BAV vs. those with trileaflet aortic valve (TAV). From May 2002 to January 2018, 177 patients including 18 BAV and 159 TAV underwent the FS procedure. Baseline characteristics, perioperative outcomes, ventricular dimensions, ejection fraction, and degree of aortic insufficiency were compared between the two groups. Kaplan–Meier analysis evaluated survival and freedom from reintervention. Mean ± standard deviation of age and aortic root diameter were comparable in BAV and TAV groups, 47.83 ± 11.19 vs. 49.59 ± 15.79 years (p = 0.55) and 56.57 ± 6.18 vs. 55.17 ± 8.84 mm (p = 0.46), respectively. Thirteen (72.22%) patients in the BAV group and 115 (72.33%) patients in the TAV group were male (p = 0.85). Left ventricular end-systolic and -diastolic diameters decreased from baseline to 1 week in BAV group (p = 0.037 and 0.12). Left ventricular end-diastolic diameter improved at both 1 week (p < 0.001) and 30-day (p = 0.001) in the TAV group (Table PC33-1). The 30-day mortality and stroke rates were zero in the BAV group and 1.88% in the TAV group (p = 1.0). One patient (5.55%) in the BAV group and 8 (5.03%) patients in the TAV group needed permanent pacemaker implantation (p = 0.62). Freedom from reoperation was 93% at 1–8 years in the BAV group and 100% at 1 and 2 years and 99% at 3–8 years in the TAV group (p = 0.041). Patients’ survival rate was 100% at 1–8 years in the BAV group and 97% at 1 year, 96% at 2–5 years, and 91% at 6–8 years in the AV group (p = 0.42). Freedom from aortic insufficiency greater than mild was 93% in the BAV group and 96.5% in the TAV group at 5 years. Table PC33-1. Comparison of Outcomes Between Bicuspid and Tricuspid Aortic Valve Patients After the Florida Sleeve Procedure Table PC33-1. Comparison of Outcomes Between Bicuspid and Tricuspid Aortic Valve Patients After the Florida Sleeve Procedure This is the first report to examine outcomes of the FS procedure in patients with BAV. This technique is feasible and the results appear durable when compared to patients with TAV. To assess the degree of oversizing with the Perceval sutureless valve at the time of implantation and related short-term outcomes including post-implantation gradients, paravalvular leak, and requirements for a permanent pacemaker. Fifty-five consecutive patients scheduled for elective aortic valve replacement were imaged with a cardiac computed tomography angiography. Detailed measurements of the left ventricular outflow tract, aortic annulus, and sinuses of Valsalva were obtained and compared against the implant size. The degree of oversizing was calculated as a percentage using the perimeter of the fully expanded valve size and the annular perimeter. Hemodynamic data from postoperative echocardiography, requirement for permanent pacemaker, and mortality within 30 days were recorded. The sizing ranged from 33% undersizing to 36% oversizing. On average the valve/annulus perimeter ratio was 0.96. Two of 55 patients had trace paravalvular leak (PVL) (3.6%, 0.4%–12.5%). The ratio in these 2 patients was 0.97 and 0.67 (the most undersized prosthesis). Four patients required a permanent pacemaker (7.2%, 2%–17.5%). The ratio in these 4 patients was between 0.86 and 1.36. There was no mortality at 30 days and the average post-implantation gradient was very low at 7.9 mmHg (range 2–14). This study reports the extent of under- and oversizing of a sutureless, surgically placed aortic bioprosthetic valve that has strong similarities with a transcatheter aortic valve replacement (TAVR) valve. In contrast to TAVR, where oversizing is pursued deliberately, our data suggest that oversizing is not required with the Perceval valve. Even with slight undersizing, in reference to the annular diameter, PVL is not commonly seen. On the other hand, oversizing may result in higher pacemaker rates and higher gradients because of restricted leaflet motion. Aortic valve replacement through a right minithoracotomy is a minimally invasive procedure not frequently used because of having been reported longer cardiopulmonary bypass and cross-clamping times compared to the standard full sternotomy. We reviewed 634 patients (350 male 55% with median age of 75; range 16–93 years) who received an aortic valve replacement between January 2010 and April 2018 through a right minithoracotomy. A total central cannulation was preferred in more than 90% of patients. The majority received an aortic valve replacement with a pericardial bioprothesis sutured using three 2/0 prolene running sutures or more recently a sutureless prosthesis (80 patients; 12%). Mean prosthesis size was 24 mm. Aortic replacement was performed through a 4–6 cm skin incision at the third intercostal space. Six patients were a REDO case. Overall median cardiopulmonary bypass and aortic cross-clamping time was, respectively, 58.5 minutes (range 25–172) and 46 minutes (range 16–134). Median ventilation time and intensive care stay were 7 and 44 hours. Patients transfused were 42%. Hospital mortality was 1.4% (9/634). This single-center experience shows that aortic valve replacement achieved through a right minithoracotomy is a safe procedure with excellent results. Thanks to a standardized technique, cardiopulmonary bypass and cross-clamping times comparable with the standard can be obtained and peripheral cannulation avoided. The implementation of a multidisciplinary patient blood management (PBM) program may contribute to a reduction in transfusion requirements, a decrease in health costs, and an improvement in patient outcomes. We compared 2 different time intervals of aortic valve replacement (via conventional and minimally invasive techniques) under different strategies of blood management. This retrospective cohort study included high-risk patients (Euroscore II >5) undergoing aortic valve surgery under different PBM strategies during the period from January 2011 until November 2018 ( Table PC36-1 ). Patients were matched for age, gender, body mass index, and Society of Thoracic Surgery score: group 1 (control): (2011–2014) N = 294 and group 2: (2015–2018) N = 277. Table PC36-1. Components of Patient Blood Management Strategies Within Years IV: intravenous; PBM: patient blood management; SAVR: surgical aortic valve replacement. The percentage of patients who received transfusion was 14.3% in group 2 and 34.6% in control (p < 0.05). Postoperative hemorrhage (group 2: 220 ± 30 and 775 ± 60 ml in control; p = 0.012), respiratory support duration (8.3 ± 2/16.7 ± 2 hours; p = 0.011) and intensive care unit stay (1.03 ± 1 vs. 2.6 ± 1.1 days, p = 0.025) were significantly better in group 2 vs. control. No difference in mortality and major complications were noted. Stepwise multiple logistic regression analysis demonstrated minimally invasive surgery (odds ratio [OR]: 5.1), minimally invasive extracorporeal circuitry (OR: 3.66), and cardioplegia type (OR: 3.2) as leading independent predictors of the reduction in transfusion. Cost analysis demonstrated 11.9% decrease in group 2 with respect to group 1 (p = 0.035). Based on the available evidence, PBM protocols are likely to be most productive for high-risk cardiac patients. The extent is in significant progress introducing minimally invasive techniques and circulation. Studies with higher patient population are still warranted. Although conclusive data compared to conventional surgery are still lacking, minimally invasive surgery is rising in proportion. This study aimed to provide a contemporary, risk-adjusted comparison of early postoperative outcomes of aortic valve replacement through a full sternotomy (CAVR) or upper ministernotomy (MIAVR). Between January 2014 and June 2018, 297 patients underwent primary, elective, isolated aortic valve replacement. Early postoperative outcomes were compared among 2 propensity-matched groups of 120 patients who had MIAVR or CAVR. Our MIAVR technique relies on 4 principles: (1) very limited skin incision and upper ministernotomy preserving the xiphoid process; (2) central aortic cannulation in order to provide anterograde arterial flow; (3) percutaneous, ultrasound, and radioscopic-guided common femoral vein cannulation; and 4) percutaneous, ultrasound, and radioscopic-guided pulmonary artery and coronary sinus cannulation for left heart venting and retrograde cardioplegia delivery, respectively. MIAVR patients had longer cardiopulmonary bypass (109 ± 26 vs. 100 ± 24 minutes, p = 0.01) and operative times (254 ± 39 vs. 226 ± 37 minutes, p < 0.001). However, aortic cross-clamp times were comparable (75 ± 22 vs. 79 ± 18 minutes for MIAVR and CAVR, respectively, p = 0.12). Overall, conversion rate was 1.7% (2 patients). MIAVR patients had less blood loss during the first 24 hours (253 ± 204 vs. 323 ± 296, p = 0.03), less red blood cell transfusions (1.4 packs [1.1–1.9] vs. 2.1 packs [1.8–2.7]), and shorter assisted ventilation time (7.1 ± 3.3 vs. 9.7 ± 3.8 hours, p < 0.001) when compared to CAVR patients. These results led to a significantly shorter intensive care unit and hospital stay for MIAVR patients (2.5 ± 1.3 vs. 3.4 ± 1.1, p < 0.001 and 6.9 ± 4.1 vs. 8.2 ± 4.8, p = 0.03, respectively) ( Figure PC37-1 ). All other postoperative outcomes were comparable between groups. Figure PC37-1. Hybrid aortic valve replacement through upper ministernotomy significantly reduced 24 blood loss (A) and postoperative red blood cell transfusions (B). Moreover, mechanical ventilatory support was suspended faster for these patients (C). Overall, minimally invasive aortic valve replacement was associated with significantly shorter ICU and hospital stays than the conventional approach (D). CAVR: conventional aortic valve replacement; ICU: intensive care unit; MIAVR: minimally invasive aortic valve replacement. MIAVR provides early postoperative outcomes at least comparable to CAVR. Moreover, it might reduce transfusions, postoperative bleeding, and assisted ventilation time quickening patient recovery. This could be of paramount importance in the elderly and frail patients. Right anterior minithoracotomy for surgical aortic valve replacement (SAVR) is effective and with excellent outcomes. We believe this approach might be safe and effective even in those patients with intermediate surgical risk (4% < Society of Thoracic Surgery [STS] risk score < 8%) and severe calcified aortic stenosis, ideally suitable for transcatheter aortic valve implantation procedures in the PARTNER 2 Trial setting. Retrospectively, from January 2010 to June 2018, we collected 102 consecutive adult patients with intermediate surgical risk, undergoing isolated SAVR for tricuspid severe aortic stenosis. Minimally invasive aortic valve replacement was performed by a single surgeon, through a 4–6-cm-long RAT at the third intercostal space without rib avulsion or ligation of the right internal mammary artery. As our standard setting, we perform a complete central cannulation with normothermic systemic perfusion and blood-based cardioplegia. All procedure went successfully. Complete central cannulation (arterial = distal ascending aorta, vein = atrial appendage) and RAT approach have been used in all cases. Baseline characteristics: male 36.36%; mean age of 83.4 ± 3.8 years; mean STS risk score of mortality 4.81% ± 0.71% (range 4.02%–6.83%) and of morbidity/mortality 24.57% ± 4,65%. Results: median implanted prosthesis diameter was 23 mm; mean cardiopulmonary bypass (CPB) duration was 49.3 ± 14.9 minutes; aortic cross-clamping time was 36.8 ± 14.7 minutes; median ventilation time was 6 hours; median intensive care unit stay 2.5 days. Observed mean bleeding rate in the first 12 hours was 476 ± 230 ml, 37.5% patients needed blood transfusion (median number of bags: 2). Pacemaker implantation rate was 2.17%. The total in-hospital stay median duration was 7 days. Observed 30-day mortality rate was 1.96%, and observed morbidity/mortality rate was 9.3%. No paravalvular aortic regurgitation more than mild at discharge was observed. Results show that our approach is safe and effective for surgical aortic valve replacement in intermediate-risk patients. RAT approach is a valid option in this subset of patients to avoid the most common complications after transcatheter aortic valve replacement procedure. Complete central cannulation is safe, avoiding the risk of peripheral CPB implantation with no impact on perioperative mortality. No-rib-spreading and video-assisted right anterior minithoracotomy aortic valve replacement (AVR) is an approach that is currently adopted by centers experienced in right anterior minithoracotomy aortic valve surgery. The effort of this endoscopic AVR collaborative group is to analyze results of AVR performed with the lowest degree of invasiveness, by trained teams and in low- and intermediate-risk patients. This is a multicentric retrospective study with a prospective data collection protocol. Centers, with surgeons who have an experience of at least 20 AVRs performed through right anterior minithoratotomies with the use of a rib retractor, were contacted to include patients in the study. Main technical features of the protocol are avoidance of a rib retractor and exclusive use of a soft tissue retractor with a limited skin incision ( 0.05) and aortic cross-clamping time (85.5 ± 28.5 vs. 84.6 ± 31.6 minutes, p > 0.05). Mitral repair rate was higher in the MIMVS group (36.5% vs. 25.0%, p > 0.05). The only exception was a more frequent tricuspid-associated procedure in the sternotomy group (50% vs. 3.5%). MIMVS outcomes compared to sternotomy showed reduction of ventilation time (37.2 ± 104.2 vs. 52.8 ± 84.9 hours, p < 0.0001), intensive care unit stay (4.0 ± 8.6 vs. 4.4 ± 5.4 days, p < 0.0279), transfusions (3.6 ± 5.1 vs. 4.3 ± 2.8, p < 0.0158), thoracentesis (2.1% vs. 15.6%, p < 0.0107), creatinine values (0.99 ± 0.46 vs. 1.23 ± 0.63 mg/dl, p < 0.0334), total complications (0.5 ± 0.9 vs. 1.3 ± 1.1, p < 0.0001), and 30-day mortality (3.1% vs. 15.6%, p < 0.0232). A propensity score (area under the curve = 0.82) was used to identify 27 patient pairs. The matched comparison confirmed a trend of advantage for MIMVS: less prolonged ventilation (7.4% vs. 15.4%), reintubation (7.4% vs. 11.1%), tracheostomy (3.7% vs. 7.4%), intensive care unit stay (2.9 ± 3.4 vs. 3.4 ± 5.0 days), patients transfused (40.7% vs. 55.6%), re-exploration for bleeding (3.7% vs. 11.1%), neurological events (7.4% vs. 11.1%), pacemaker implantation (0.0% vs. 7.4%), and hospital stay (10.5 ± 4.2 vs. 11.6 ± 7.3 days), respectively. Significant advantage for MIMVS remained in ventilation time (22.5 ± 29.5 vs. 40.3 ± 77.5 hours, p = 0.0105) and total complications (0.6 ± 0.9 vs. 1.1 ± 0.9, p = 0.01539). In octogenarians MIMVS is feasible, reduces hospitalization, complications, and postoperative morbidity and allows early postoperative mobilization as well as improved quality of life. Thoracoscopy-assisted minimally invasive mitral valve repair (MICS-MVR) through a small right thoracotomy is a novel technique for mitral valve surgery and is increasingly adopted worldwide. This study aims to identify areas of improvement by describing characteristics of MA’s tri-port chest thoracoscopic cardiac surgery and mid-term outcomes of a series of MICS-MVR. This surgical breakthrough is known as the MA technique (MAT) in clinical literature. MAT was first pioneered by the author and his research team in 2009. It is a form of totally thoracoscopic heart surgery conducted through three ports on the right chest wall and belongs to the field of microsurgery. The associated procedure is simple and effective, leading to minimal surgical trauma. As of October 2018, MAT has witnessed 2,166 cases of successful application. Among them, 762 cases treated for rheumatic mitral valve disease involved patients aged 32–81 years and weighed from 43 to 106. Moreover, 697 treated cases consisted of mitral valve replacement and 55 cases for mitral valvuloplasty. An additional 36 control patients were recruited to undergo open-chest MVR. Patient information is collected for further statistical analysis. The data processed include but are not limited to preoperative cardiac information, operation time, cardiopulmonary bypass (CPB) time, cardiac arrest time, intensive caer unit (ICU) stay duration, ventilator-support time, hospitalization period, postoperative drainage volume, blood transfusion rate, incidence of morbidity, rate of mortality, and postsurgery assessment. Postsurgery information points to a 14.3% blood transfusion rate and a postoperative ventilator-support time ranging from 3.1 to 29.4 hours (with a mean and deviation of 5.1 ± 0.8 hours). Similarly, pleural fluid drainage ranged between 45 and 650 ml (95 ± 26 ml). The research team tabulated a 19-hour average ICU stay length with a range of 3–56 hours. An average 6.1-day postsurgery hospitalization time that ranged between 4 and 14 days for all 762 treated cases of rheumatic mitral valve disease was also computed. It is pertinent to note that there were 2 cases of death, 2 cases that required conventional open surgery, 9 cases of pulmonary infection postoperative, and 12 cases of secondary hemostasis. The team tracked 750 cases for 1–94 months in a subsequent follow-up. This group of patients had 3 cases of death in post-hospital discharge, and 2 cases of death resulting from cardiac causes. Compared to the control group, MAT significantly reduces the time associated with surgical operation, CPB, cardioplegia, ICU length of stay, ventilator support, and hospitalization. Additionally, MAT has smaller odds of complication and postoperative drainage while lowering the rates of blood transfusion and use of pain medication. Through repeated surgical amendments, MAT has evolved to deliver clinical excellence and is more advantageous than the conventional surgery. It overcomes the drawbacks of small-incision-based cardiac surgery in terms of field of vision, procedural challenges, surgical trauma, and postsurgical pain in tandem to circumventing the shortcomings of robotically assisted heart surgery. To report early and late clinical results comparing right minithoracotomy (RMT) versus full sternotomy (FS) mitral valve surgery (MVS). Five hundred seventy-four consecutive patients who underwent MVS were prospectively nonrandomized reviewed during January 2002–October 2018. There were 241 in FS group and 241 in RMT group by propensity matching. Baseline characteristics were compared. Early and late clinical outcomes of 30-day mortality, reoperation for bleeding, stroke, prolonged ventilation, renal failure, permanent pacemaker, and echocardiographic hemodynamic performance were assessed and compared between 2 groups. Similar results were found between RMT and FS MVS groups including age 58.8 ± 13.6, 57.2 ± 14.2, p = 0.2, new atrial fibrillation 5 (2%), 4 (1.7%), p = 1.0, and reoperation for bleeding 2 (0.8%), 1 (0.3%), p = 0.9. There were more degenerative valve pathology (79%, 45.6%, p < 0.001), less aortic cross-clamp time (107 ± 37.3, 115.4 ± 36.4, p = 0.017), less cardiopulmonary bypass time (157.6 ± 51.2, 171.3 ± 53.4, p = 0.005), less bleeding, and blood transfusion requirement in the RMT group. Early clinical results of 30-day mortality, stroke, renal failure, new pacemaker, and hemodynamic performance at 1 month, 3–6 months, and 1 year were comparable in both groups. Mean follow-up (year) was 5.2 + 2.5 (RMT) and 10.2 + 4.0 (FS). Survival probability and freedom from major cardiac and cerebrovascular events at 10 years in the RMT and FS groups were 94.05%, 95.44% and 99.5%, 90.46%, p < 0.001, respectively. RMT approach for MVS is associated with cosmetic satisfaction, less bleeding, blood transfusion requirement, similar effective hemodynamic performance, and comparable early and late clinical results to FS approach. To investigate the efficiency and safety of totally endoscopic tricuspid ring annuloplasty technique on beating hearts in combination with atrial septal defect (ASD) repair. Twenty-four patients (39–71 years, mean 52.2 ± 12.3) underwent ASD closure and tricuspid ring annuloplasty on beating hearts by a totally endoscopic approach. All of them had moderate-to-severe tricuspid valve regurgitation (TVR) with mean pulmonary artery pressure (PAP) was 61.8 ± 10.89 mmHg. Cardiopulmonary bypass was achieved peripherally. Three 5-mm trocars and one 12-mm trocar were used; only the superior vena cava is snared, filling the pleural and pericardial cavities with CO2. Tricuspid ring placement was successful in all cases. No extension of the incision was needed. Mean bypass time was 90.2 ± 12.04 minutes. After surgery, there were 15 cases with nontrivial TVR and 9 cases with mild TVR. Postoperative mean PAP was 28.4 ± 12.19 mmHg. No arrhythmia or atrioventricular block was recorded. Tricuspid ring annuloplasty in nonrobotic totally endoscopic ASD closure on beating hearts is a safe and an efficient technique. Figure PC45-1. Advance technological improvement has facilitated the implementation of minimally invasive approaches in cardiac surgery even for redo interventions. Redo heart valve surgeries via sternotomy are associated with substantial morbidity and mortality. This study evaluated the minimally invasive technique for heart valves implantation in patients undergoing redo cardiac surgery. Three hundred eighty-five patients underwent aortic, mitral, and/or tricuspid valve repair or replacement via a right minithoracotomy between June 2013 and December 2018 in our center, and 45 patients underwent redo valve surgery using a minimally invasive approach. Previous cardiac surgeries included 14 patients with aortic and mitral valve replacement, 19 patients with coronary artery bypass grafting, and 12 patients with mitral valve repair or replacement. In all cases, femoro-femoral cannulation was performed. Three-dimensional video-assisted access technique was applied in all patients concomitantly. Most of the operations were performed using normothermia cardiopulmonary arrest except in the cases with isolated tricuspid valve repair or replacement and isolated mitral valve repair (n = 5) in whom the aortic valve competence was normal. In addition, continuous carbon dioxide is used, and adequate de-airing is monitored by transesophageal echocardiography. In all cases, a sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. The outcomes of patients (in-hospital mortality about 1.55%) are encouraging and intraoperative times are highly competitive with published data on the standard full sternotomy. Time of surgery and cross-clamp time were compared with the overall series (168 ± 73 [redo] vs. 168 ± 58 minutes and 52 ± 21 [redo] vs. 58 ± 25 minutes). Two patients had transient hemiplegia due to air embolism. All other patients had uneventful outcomes and normal valve function at first-year follow-up. Redo valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right anterior or lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and, thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery. Mitral valve surgery in patients who have undergone coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) is of particular risk when performed through redo sternotomy. The outcome of minimally invasive mitral valve surgery (MIMVS) via a right anterolateral minithoracotomy (5–7 cm) that can also be performed without aortic clamping has not yet been evaluated in these patients. From 534 patients undergoing MIMVS between January 2012 and April 2018 at our institution, 10 patients (median age 72, 8 male) required MIMVS at 99 months (33–179) postoperatively. Nine of the 10 patients underwent the procedure under hypothermic ventricular fibrillation without aortic clamping. The preoperative, intraoperative, and postoperative data were retrospectively collected and analyzed. Preoperative left ventricular ejection fraction (LV-EF) was 44 (30%–55%) and EuroScore II was 25.0% (6.7–33.0). Mitral valve replacement with biological prosthesis was performed in 8 (80%) and reconstruction in 2 (20%) patients. Four patients (40%) required concomitant tricuspid valve repair. There was no conversion to sternotomy, no intraoperative death, no postoperative neurological deficit, no bypass damage, and no myocardial infarction. Reoperation for bleeding was required in 2 patients, whereas cardiac resuscitation was required in 1 patient. Reintubation was necessary in 3 (30%) patients and temporary hemodialysis in 4 (40%) patients all suffering from sepsis. Cardiac arrhythmias were documented in 6 patients, from which one required pacemaker implantation. The median intensive care unit stay was 5 days (3–10), whereas hospital stay was 9 days (7–19). Mortality at discharge was 20% and was associated with resuscitation and sepsis. All discharged patients (80%) survived the follow-up period of 21 months (9–29) without complications. MIMVS can be performed safely after BIMA CABG also in elderly patients with reduced LV-EF. The low mortality was not related to the operative characteristics and postoperative cardiac function, but rather to advanced age, postoperative need for mechanical ventilation and dialysis, development of sepsis, and multiorgan failure. Surgical robotics allows incision size to be dramatically reduced with expedited postoperative recovery. Percutaneous approaches to cannulation have reduced the morbidity of transcatheter procedures. We report our early experience performing totally endoscopic robotic cardiac surgery with percutaneous access. From July 2018 through December 2018, 29 consecutive patients underwent totally endoscopic robotic cardiac surgery with percutaneous peripheral cannulation. The mean age was 62.3 years (34–80), 13 male, 16 female, and mean body mass index 29.8 (19.6–58.1). Robotic procedures included mitral valve repair (17), mitral valve replacement (5), atrial septal defect closure (3), septal myectomy (2), and atrial mass resection (2). Thoracic access was composed of four 8-mm robotic ports. Additionally, there was one 12-mm working port for the bedside assistant, except mitral valve replacement that requires a 35-mm port. All percutaneous cannulation were achieved with surface ultrasound, transesophageal echocardiography, and fluoroscopic guidance. Percutaneous pulmonary artery vent and retrograde cardioplegia catheters are placed by anesthesia. The surgeon places a common femoral multistage venous canula, common femoral arterial canula, and internal jugular venous canula for superior vena cava drainage. A preclose technique is used to facilitate decannulation. The aorta was occluded using an endoaortic balloon. Lower-extremity perfusion is monitored continuously with tissue and pulse oximetry. At the conclusion of the case, vascular Doppler ultrasound is used to confirm arterial flow. The mean hospital stay was 4.7 days (1–16). Aortic clamp and cardiopulmonary bypass times were 75.9 (29–108) and 119.1 (67–148) minutes, respectively. No patient was converted to thoracotomy or sternotomy. There were no hospital or follow-up mortalities. There was one patient with acute limb ischemia following deployment of a percutaneous vascular closure device related to a posterior plaque. This was immediately diagnosed, and an endarterectomy was performed with good result. All patients have reported no pain at the site of cannulation and there have been no lymphoceles or other complications related to cannulation. Our experience with endoscopic robotic cardiac surgery with percutaneous cannulation suggests that this technique is both feasible and safe. To our knowledge these cases represent the smallest-incision open heart surgery currently being performed in the world today. Table PC48-1. Robotic Endoscopic Cardiac Surgery with Percutaneous Cannulation AV: atrioventricular; BMI: body mass index; VATS: video-assisted thoracoscopic surgery. Thymectomy is the most important treatment for anterior mediastinal mass and myasthenia gravis (MG). Until now, different surgical approaches have been described to perform thymectomy, from median sternotomy to robotic thymectomy. But there is no consensus on the best approach of thymectomy. Depending on the approach to perform thymectomy, the advantages and disadvantages are different. Currently, the lateral intercostal approach in video-assisted thoracoscopic surgery thymectomy (VATS thymectomy) is the most frequently performed surgical approach for thymectomy. But this approach has difficulty to identify the contralateral phrenic nerve and intercostal nerve impairment. Recently, to overcome the shortcomings of VATS thymectomy, subxiphoid single-port thymectomy (SPT) was introduced. We have performed modified subxiphoid SPT using our own manufacturing sternal retractor without carbon dioxide insufflation under one-lung ventilation. We report the initial operative results of modified subxiphoid SPT. Subjects of this study were patients who underwent thymectomy or extended thymectomy at Inje University Haeundae Paik Hospital between July 2016 and November 2018. We reviewed the medical records of these patients retrospectively. Indication of thymectomy is anterior mediastinal mass without tumor invasion. In our department, we performed thymectomy for anterior mediastinal mass in the absence of MG. And extended thymectomy, which involves the removal of all adipose tissues anterior to the phrenic nerve, was performed for MG. Subxiphoid uniportal thoracoscopic thymectomy was attempted first in July 2016. From this time, thymectomy for anterior mediastinal mass or extended thymectomy for MG was preformed via SPT with sternal retraction. All surgical procedures were performed by a single surgeon. Twenty nine patients who underwent thymectomy or extended thymectomy were enrolled. Information of patient demographics, and intraoperative and postoperative data were collected and retrospectively evaluated. The patient’s demographics are presented in Table PC49-1. The results of operative outcome of subxiphoid SPT are presented in Tables PC49-2 and PC49-3. Table PC49-1. Patients’ Demographics Table PC49-1. Patients’ Demographics Table PC49-2. Operative Outcomes Table PC49-2. Operative Outcomes Table PC49-3. Pathologic Diagnosis Table PC49-3. Pathologic Diagnosis The benefit of subxipohid approach with sternal retraction is that it makes it easier to identify the contralateral phrenic nerve. Also, our procedure has 3 advantages when compared with carbon dioxide insufflation subxiphoid SPT. First, because we do not insufflate carbon dioxide, there is no need to worry about hypotension. Second, we do not use air tight trocar, so we use more instruments and have more flexibility in them. Finally, sternum retraction provides more optimal space for the surgery. SPT through the subxiphoidal incision using sternal retractor under one-lung ventilation without carbon dioxide insufflation was feasible. Pericardial effusion, besides being a complication of cardiac surgery, may be caused by renal impairment, infections, neoplasms, or autoimmune diseases. As it is not simple to diagnose its etiology, pericardial drainage is often necessary for both therapeutic and diagnostic purposes. The target of this study is to demonstrate the safety, simplicity, and usefulness of subxiphoid drainage. Between September 1, 2015 and September 30, 2018, 12 patients underwent subxiphoid drainage, 7 patients had a failed pericardiocentesis, 2 patients had late pericardial effusion after cardiac surgery, and 10 had pericardial effusion of an unknown origin. Six patients underwent emergency drainage. All procedures were performed in awake patient without intubation. After Xylocaine local anesthesia, a 3-cm incision was performed above the xyphoid process. Once the pericardium was opened, liquid samples were sent for chemical-physical, cytological, and bacteriological examination. Also, it was always possible to send a fragment of pericardium for histological examination. A small drainage was placed and wound closed. No patient died due to the procedure, and no patient required intubation or intensive care stay. All patients were discharged 48 hours after the procedure. Excluding cardiac surgery patients, the etiology was uremic in 2 patients, infectious/viral in 2, malignant in 3, and idiopathic in the rest of the cases. No patient had a recurrence of pericardial effusion after 30 days. Subxiphoid pericardial drainage is a simple and a safe procedure, even in patients undergoing cardiac surgery in the past, where pericardiocentesis could be difficult and dangerous. It does not require intubation of the patient and above all no need for long hospital stay. It allows to send pericardial portions useful in the differential diagnosis of tumor pathology. Thoracic surgery has seen a significant increase in the use of robotic-assisted thoracoscopic surgery (RATS) with an aim to replace current video-assisted thoracoscopic surgery (VATS). Thymectomy is a common procedure used in the early stages of RATS training to introduce surgeons to the robotic method. The aim of this project is to evaluate the early learning curve of RATS compared with VATS for thymectomy and its impact on length of stay. Data were prospectively collected between 2015 and 2018 for all VATS and RATS thymectomy cases completed in a tertiary thoracic center. Baseline patient characteristics, operating times, and length of stay were recorded in the chronological order of date of surgery. All cases that were converted to sternotomy were discounted from analysis. Median (interquartile range) operating times were calculated and linear regression analysis completed to assess correlation between operating times and days from first procedure for RATS cases, initial VATS cases, VATS cases performed by the robotic surgeons, and all VATS cases performed in the center. Mann–Whitney U test was used to compare the length of stay between RATS and VATS. p < 0.05 was considered significant. There was a total of 41 thymectomies performed comprising of 31 VATS and 10 RATS procedures. The median operating time for all VATS thymectomies (n = 31) was 137 (56) minutes (r2 = −0.1004, p = 0.0825). For the surgeons now performing RATS thymectomy, the median VATS operating time (n = 21) was 133 minutes (55.5) (r2 = −0.111, p = 0.1399) with the median time for their first 10 VATS thymectomies 147 minutes (63.8) (r2 = −0.2855, p = 0.1116). RATS thymectomy operation times had a median of 136.5 minutes (47.8) (r2 = −0.2224, p = 0.1688) and have crossed the median operating time for all VATS thymectomies performed in the center. Mean length of stay was 2 days in RATS thymectomy and 4 days in VATS thymectomy (p = 0.006). Figure PC51-1. RATS operations with median VATS time X = Time from first operation (days), Y = Operation time (min) RATS: Robot-assisted thoracoscopic surgery, VATS: Video-assisted thoracoscopic surgery. Transfer of the surgical skills of thymectomy from video-assisted to robotic-assisted surgery helps surgeons achieve similar initial learning curves and may explain the reduced operating times in early RATS thymectomy. The benefit in reduction of length of stay supports the adoption of RATS in other aspiring thoracic centers. Hydatid cyst caused by Echinococcus granulosus is endemic in Asia. Pulmonary hydatid does not have a uniform treatment recommendation. This case series presents the thoracoscopic management of hydatid disease from India. Retrospective multicentric case series of patients treated between 2003 and 2018 at three multispeciality centers was included in this study. Twenty-one patients with an average follow-up of 17 months were included. Thoracoscopic surgery was performed in all 21 patients with a mean duration of hospital stay of 5 days and mean age 33 years, and there was no recurrence noted at 6 months follow-up. Thoracoscopic surgery helps in faster recovery early back to work and there were no added complications and hence needs to be offered in all patients with hydatid cyst. Pulmonary metastasectomy is a commonly performed operation and tends to further increase as part of a concept for personalized treatment in advanced stages of cancer. Various surgical tools have been utilized to improve the resectability of pulmonary metastases while reducing the rate of complications: from electrosurgical instruments and mechanical staplers to Nd:YAG laser. More recently, pure argon plasma has provided an electrically neutral energy source for cutting and coagulating tissue with minimal depth of necrosis. These characteristics make argon plasma energy an appealing candidate for pulmonary metastasectomy, where the goal is complete excision of the lesion with simultaneous aerostasis, hemostasis, and preservation of lung parenchyma. In this study, we assess the safety and efficacy of thoracoscopic pulmonary metastasectomy with argon plasma energy and we compare its clinical results with those observed by using more conventional surgical technologies. During a two-month period, 5 patients (3 males and 2 females) aged between 67 and 85 years (mean age of 77 years) underwent uniportal video-assisted thoracoscopic surgery for pulmonary metastasectomy with the use of argon plasma energy. All patients had a medical history of colorectal carcinoma and presented with a solitary, less than 3 cm in maximal diameter, peripherally located lung lesion with radiological features suspicious for metastasis. In all cases, histopathological analysis of the lesion confirmed colorectal metastasis that was completely excised. The mean operative time was 22 minutes (range, 18–25). All surgeries were performed without complications, including bleeding and air leakage, thus allowing removal of the intercostal chest drain on the following day. All patients were discharged on the first postoperative day and were followed up for a mean period of 6 months (range, 4–8 months), during which no complications occurred. The use of argon plasma energy for thoracoscopic excision of pulmonary metastases appears to be simple, safe, and efficacious. When compared to more conventional surgical techniques, argon plasma energy represents a valid alternative method for pulmonary metastasectomy. Intercostal thoracic surgical incisions are painful and in the postoperative period following open or thoracoscopic surgery patients typically require significant amounts of opioids to provide adequate perioperative analgesia. However, the use of opioids is commonly associated with adverse effects such as opioid-induced hyperalgesia, sedation, nausea and vomiting, and postoperative ileus. It is recognized that these complications can delay patient mobilization and hospital discharge. We have successfully piloted the use of opioid-free anesthesia (OFA) in patients undergoing lung cancer resection at our center. All data were recorded prospectively. The anesthetic technique comprised induction of anesthesia with intravenous lidocaine, propofol, and nondepolarizing muscle relaxant; locoregional analgesia (i.e. serratus anterior plane block or paravertebral block) and pre-incision paracetamol, parecoxib, and magnesium sulfate as routine. Clonidine and phrenic nerve blocks were also used in selected patients. All patients received postoperative patient-controlled analgesia with morphine. Continuous data are presented as mean ± standard deviation; nonparametric data are expressed as median (interquartile range [IQR]). During the pilot, 37 patients were included in the study: 23 male and 14 female. The mean age was 67.7 ± 10.3 years. The mean body mass index was 28.3 ± 5.7 kg/m2with median American Society of Anesthesiologists’ status 3 (range 2–4). The mean percentage predicted forced expiratory volume in 1 second was 88.0% ± 23.1%. The mean 6-minute walk test distance was 367 ± 108 m. The surgeries included 32 lobectomies and 5 anatomical segmentectomies; 31 procedures were performed thoracoscopically (28 uniportal, 2 subxiphoid, and 1 multiportal) and 6 were performed by thoracotomy. The mean duration of surgery was 189 ± 58 minutes. The mean length of stay in the postanesthetic recovery area was 114 ± 37 minutes. The mean opioid consumption of the patients within the first 24 hours was 15.5 ± 20.7mg. The median hospital length of stay was 3 days (IQR 2–4). We have demonstrated that OFA is feasible and safe in patients undergoing thoracic surgery and it should be considered as part of the enhanced recovery programmes, to minimize the complications associated with the perioperative use of opioids. The introduction of the robotic system in thoracic surgery has revolutionized the treatment of pulmonary and mediastinal pathologies. Over the years, different technological upgrades have allowed the surgeons to change the technique. The aim of this study was to illustrate the impact of three upgrades in robotic thoracic surgery: the use of robotic staplers for lung resections, the green indocyanine infusion associated with intraoperative infrared vision for identification of pulmonary nodules and phrenic nerve during thymectomies, and the technical improvements between third and fourth generations of robotic system. We retrospectively analyzed 20 patients who underwent anatomic pulmonary resection for non-small-cell lung cancer (NSCLC) from January 2015 to January 2016. Patients were divided into 2 groups: group I: 10 patients, resections performed with robotic staplers and group II: 10 patients, resections performed with endoscopic staplers. We evaluated the effectiveness in terms of postoperative complications and postoperative pain. We evaluated 20 patients in which the indocyanine green infusion was used for the visualization of suspicious nodules for NSCLC (5 patients) and visualization of the phrenic nerve during thymectomies (15 patients). We retrospectively evaluated 52 patients who underwent robotic thymectomy (group I: 23 patients treated using the 3rd robotic generation, group II 29 patients treated with the 4th generation). We evaluated effectiveness in terms of postoperative pain and analgesic request. Figure PC55-1. No postoperative complication in both groups. Lower mean numerical rating score (NRS) and analgesic request in group I. The use of indocyanine green has proved to be useful in the identification of invisible pulmonary nodules and in the execution of thymectomy in case of thymomas adjacent to the phrenic nerve. We found a statistically significant difference in the mean value of the NRS 24 hours after surgery (p < 0.05). Group I 4.07 (standard deviation [SD] 2.51), group II 1.72 (SD 1.15), and a statistically significant difference in the administration of analgesics. Group I 2.62 administrations (SD 0.94), group II 1.52 administrations (SD 1.12) 1 day after surgery. The evolution of technology has improved the execution of robotic surgical procedures with a positive impact on postoperative outcomes. Video-assisted thoracoscopic surgery (VATS). We present a case of successful removal of an 8.5-cm noncompliant mass with a broad attachment to the parietal pleura. We describe a complex clinical case report of a patient who underwent VATS mass resection. We describe a 34-year-old male who presented to University Medical Center after an acute onset of dyspnea. A chest radiograph and subsequent computed tomograph chest revealed a large posterior mediastinal mass at 8.0 × 8.0 × 8.5 cm. Mass excision was scheduled by VATS vs. thoracotomy. The attachment to the parietal pleura was very broad with an array of venous and arterial vasculature. A 30° camera scope was able to maneuver tight imaging windows. Some bleeding was encountered that was easily controlled with sponge stick and pressure. The posterior mediastinal mass was successfully removed by VATS resection. VATS as a minimally invasive surgical resection for a large posterior mediastinal mass is not well described. Tumor greater than 4 cm is a soft contraindication to VATS removal. The benefits of VATS vs. thoracotomy have been thoroughly explored. Knowing when to convert given bleeding, loss of visualization, and inability to perform with appropriate dexterity are all reasonable concerns leading to thoracotomy conversion. An algorithm must also exist for the more senior surgeon contemplating when one should and could remain in VATS. Several types of annuloplasty rings and bands have been used in mitral valve repair (MVP) with different concepts, but their actual effects on left ventricular hemodynamics especially on mitral inflow and aortic outflow have not been fully revealed. We performed vortex flow evaluation with four-dimensional (4D) flow magnetic resonance imaging (MRI) in patients after MVP. Twenty-one normal controls, 7 patients with CG future band (CG), 5 with Physio II ring (PHY), and 1 with Tailor band (TA) with different sizes were examined in 4D flow MRI. Influences of annuloplasty procedure types on diastolic intraventricular vortex flow patterns and systolic aortic outflow patterns were examined in addition to flow energy loss (EL) in 1 cardiac cycle. The band sizes of CG were 28 mm in 1 patient, 30 mm in 1, 32 mm in 1, 34 mm in 2, and 36 mm in 2, and the ring sizes of PHY used were 28 mm in 1 patient, 30 mm in 1, 32 mm in 1, 34 mm in 1, and 36 mm in 2, and the ring size of TA used was 33 mm. Diastolic intraventricular flow after MVP made larger vortices beneath anterior and posterior leaflets compared with those in normal controls. Anterior vortices after MVP were consisted of 2 strands. Relationship between EL and the transmitral mean pressure gradient during diastole was significant (r = 0.63, p = 0.04). In systole, some patients with smaller rings or bands compared with patient’s body size had disturbed outflow due to vortex flow inside left ventricle (LV), resulting in high EL. PHY restricted aortic annulus systolic motion, and then it caused slight EL elevation with EL distribution pattern changed. Mean arterial pressure patients had larger left ventricular vortex in diastole regardless of the repair type than the healthy volunteer. In systole, small-size annular ring or band caused narrowed LV outflow pattern. The effect of vortex flow pattern change on long-term ventricular function after the MVP is to be studied. Aortic valve reconstruction with three same-sized autologous pericardial leaflets (AVLR) has been performed for patients with narrow aortic roots or contraindication for valve prostheses. Since this procedure requires precise information of the aortic root including configuration of Valsalva sinus, we assessed physiologic-anatomical condition of the aortic root by virtual reality (VR) image in order to accomplish this technique with a reproducible fashion. VR imaging; axial images using enhanced electrocardiogram-triggered cardiac computed tomography with a slice thickness of 0.625 mm were obtained during mid-to-end diastole. Subtracted volume rendering data of the aortic root were converted to a 3D workstation. Basic surgical technique: (1) three same-sized leaflets from autologous pericardium were prepared by original templates referred by STJ diameter; (2) new commissures and nadirs were confirmed based on VR image in cases of unbalanced aortic root, like type 0 bicuspid valve; (3) three leaflets were sutured on cusp-suture-line; (4) commissure coaptation stitches were placed between each leaflet to prevent from minor leakage and coronary orifices obstruction. Twenty-four of 82 AVLR were evaluated by VR. In 15cases, the Valsalva sinus was unbalanced, which required neo-commissure setting and adjustment of deviated nadir. Postoperative echocardiography revealed nice opening of new leaflet with no aortic regurgitation, although we had one case without 3D analysis who had taken down to AVR due to mild AR. A median follow-up period was 38 months, while we have no redo due to aortic valve failure. VR image analysis had notably provided valuable information for understanding of precise anatomy of the aortic root for AVLR. The validity of the high-frequency epicardial ultrasound (ECUS) in coronary artery bypass graft (CABG) has been described. However, the echo image is a partial cross section and is insufficient for the evaluation of three-dimensional (3D) structure. So, we intended for visualization and evaluation of CABG anastomosis by performing the real-time 3D construction of the ECUS images. ECUS we have chosen was VeriQ C (MEDISTIM, Oslo, Norway) to obtain the ultrasound images, and attached the electromagnetic position-tracking sensor (trakSTAR, Ascension Technology Corp., Sherburne, Vermont, USA) to ECUS probe. We implemented the function for integrating scanned ultrasound images with positional information and making them 3D in real time with the open-source 3D Slicer application (www.slicer.org), SlicerIGT extension (www.slicerigt.org), and PLUS toolkit (www.plustoolkit.org). We evaluated this system using CABG anastomosis model, which was made with the extracted pig heart. Harvested right coronary artery was anastomosed to left anterior descending artery, and normal saline was injected from the graft continuously. We scanned the CABG anastomosis model and created the 3D images ( Figure PC59-1(A) ). Figure PC59-1. Real-time three-dimensional imaging of coronary artery bypass graft anastomosis. (A) The system which built 3D image by the combination of ECUS and positional information sensor. (B) Scanned ECUS along LAD and provided a 3D image in real time. 3D: three-dimensional; ECUS: epicardial ultrasound; LAD: left anterior descending artery. Bypass graft and anastomosis evaluation using ECUS is valuable, because it describes the vessel lumen and anastomotic form more exactly. The anastomotic 3D construction was possible by volume rendering of the ultrasound images merging image stack on the z-axis with general-purpose software, but it needs too much editing time and it is unsuitable for intraoperative use. On the other hand, our method becomes able to edit the 3D image in a few minutes ( Figure PC59-1(B) ) and we can evaluate the anastomotic quality instantly. Furthermore, indications by 3D viewer or write output into 3D printer are possible. It is useful to view the anastomotic form from multidirectional angles. Real-time evaluation of the anastomotic form was enabled by 3D building of ECUS images by combining a position sensor. And it may be used for intraoperative graft evaluation in future by improving precision. To share this novel approach to a complex situation. A 68-year-old male had previously undergone an aortic valve replacement (AVR) in 2006. Subsequently he required a redo AVR and root replacement in 2016 but this was complicated by worsened mitral regurgitation, resulting in the need for a salvage mitral valve replacement via thoracotomy. Unfortunately this was further complicated by a trapped valve leaflet. He recovered well initially but represented with worsening heart failure. Due to the high risk of sternotomy, a transventricular cardioscopic release of the trapped mitral valve leaflet was undertaken. The procedure was successful and the patient was discharged home on day 12. This is a novel minimally invasive approach for high-risk patients with this rare complication. This technique is carried out using small incisions and negates the need for myocardial ischemia. We hope that by sharing it, others will consider this approach in the future. The aim of our study was to evaluate outcomes of a redo cardiac surgery using the endoscopic vaso-view system to facilitate sternal re-entry. Between May 2016 until June 2018, a total of 29 patients underwent redo cardiac surgery using the endoscopic vaso-view system introducing the blunt dissector through a small substernal incision, which facilitates blunt dissection of adhesions underneath the sternum making a space between the sternum and the heart under vision then followed by a sternotomy with an oscillating saw. All patients had preoperative computed tomography scan. A total of 29 patients were identified and the procedures performed were valvular surgery in 82% and coronary artery bypass grafting in 18% at King Fahad Armed Forces Hospital. Twenty-four percent were second redo and 76% were first redo. The patients’ characteristics were that the mean age was 55 ± 32 years, 65% were female, 45% were males, and mean left ventricular ejection fraction was 50% ± 30% with an average EuroSCORE II of 4.8 ± 1.6. Intraoperatively patients had femoral cannulation in 20.6%, central cannulation in 71%, and off pump in 3.4%, while the mean bypass time was 125 ± 20 minutes, cross-clamp time 111 ± 10 minutes, and 6.8% had right ventricular injury. Overall in-hospital mortality was 3.5%, mean intensive care unit stay 5 ± 3 days, and length of stay 16 ± 10 days. There was no reoperation for bleeding, mean blood loss in the first 24 hours was 474 ± 230 ml, number of blood products used intraoperatively was 1.4 ± 1 units and postoperatively 1.5 ± 1 units, stroke rate was 6.8%, atrial fibrillation 38%, and myocardial infarction 3.5%, there was no renal failure requiring dialysis, and 13.7% had prolonged ventilation. Redo cardiac surgery using the endoscopic vase view system to facilitate sternal re-entry showed that it is a safe and effective approach in our hands to clear adhesions under vision facilitating sternal re-entry. A comparative study will be our next step to validate our conclusion and encourage surgeons to adopt this approach. Minimally invasive coronary artery bypass surgery in selected patients can be performed safely and efficiently, with the markedly reduced postoperative length of stay when compared to conventional surgical revascularization. A left thoracotomy is preferred during minimally invasive direct coronary bypass (MIDCAB) for both left internal mammary artery (LIMA) harvesting and performing the anastomosis. However, LIMA harvesting is sometimes challenging via the thoracotomy, which makes some surgeons prefer not to harvest the proximal LIMA. We reported our experience in three-dimensional (3D) video-assisted LIMA harvesting in MIDCAB surgery. Twelve patients who underwent MIDCAB surgery had 3D video-assisted LIMA harvesting. In these patients, LIMA was harvested in the closed chest through 3 ports, 2 for surgical equipment and 1 for the 3D camera. Following the harvest, thoracotomy was performed for off-pump left anterior descending (LAD) artery-LIMA anastomosis. All the patients underwent 1 vessel MIDCAB surgery and LIMA was anastomosed to the LAD, following video-assisted harvesting. LIMA was harvested including the first branch and finished at the level of the distal bifurcation. Mean harvest duration was 31 + 9 minutes, and the mean operation time was 107 + 19 minutes. All the LIMA grafts harvested were anastomosed and there was no sternotomy conversion. Minimally invasive coronary procedures are becoming an important option for the treatment of coronary artery disease especially with the addition of 3D visions and robotic arms lately. Three-dimensional video assistance in closed chest allows LIMA harvesting in a safe and efficient way. In mitral valve (MV) surgery after previous sternotomy, right minithoracotomy and fibrillatory arrest (FA) offer the simplest approach with no need for mediastinal adhesiolysis. Despite this advantage, limited dissection and fibrillating heart sometimes yield limited exposure. A three-dimensional (3D) endoscope might facilitate to visualize and manipulate the MV, which enables totally endoscopic surgery. We present the earliest Korean experience of applying 3D endoscopic system in redo MV surgery with FA. Between May 2018 and November 2018, we performed aortic no-touch totally endoscopic redo MV surgery on 16 patients, 2nd time in 12 patients, 3rd time in 3 patients, and 4th time in 1 patient. All patients had undergone previous valve surgeries involving MVs only through sternotomy approach (EuroScore II 11.09% ± 7.91%). Previously implanted prosthetic aortic valves existed in 6 patients. All procedures were performed through 5–6 cm right minithoracotomy incision with 2 extra ports: a left atrial sump drain and a 10-mm scope trocar ( Figure PC63-1 ). Temporary pacing wires were implanted on the right ventricular anterior wall or right ventricular endocardium after right atriotomy, and left atrium was opened after inducing FA with a fibrillator. Figure PC63-1. Mean cardiopulmonary bypass time was 175.1 ± 33.4 minutes. No intraoperative events such as great vessel injury or lung laceration occurred. There were no perioperative mortality, postoperative bleeding reoperation, low cardiac output syndrome, pneumonia, or wound problem. One minor stroke (cerebellar embolic infarction) occurred in a patient with third-time redo MV replacement. Concomitant procedures including tricuspid valvuloplasty in 10 and maze procedure in 3 were performed. Our experience illustrates feasibility and safety of the 3D totally endoscopic right minithoracotomy approach under FA to treat mitral pathology without reoperative sternotomy risks. In the decision making of the surgical treatment of acute aortic dissection, the detection of the entry site is considered important. However, its accurate detection is sometimes difficult, because the computed tomography (CT) image is inevitable from the motion artifacts caused by the heartbeat. Electrocardiogram (ECG)-gated CT scanning can reduce such artifacts and may be useful in determining the entry site of aortic dissection. The accuracy of the entry-site detection was compared between ECG-gated CT images (sync images) and nongated CT images (async images). We extracted 20 CT images (9 sync and 11 async) from patents undergoing surgical repair of aortic dissection. Six physicians (2 cardiac surgeons, 2 radiologists, 2 medical interns), who were not informed the results of operations, participated in the study. The examinee reviewed the CT images to determine the entry site of aortic dissection, and the answers were verified with the operative findings. The examinee scored each CT image according to the easiness of entry site identification into a 5-point scale. The entry site was correctly determined in 22.7% for async images. The correction rate was improved to 70.4% for sync images (p < 0.001). The difference was remarkable in medical interns or cardiac surgeons (async: 9.1% vs. sync: 63.9%), compared with the radiologists (50.0% vs. 83.3%). The average readability score was higher in sync images (async: 2.8 vs. sync: 4.5). The accurate detection of the entry site based on the conventional CT images may be difficult for nonprofessionals. ECG-gated CT scanning is considered useful to determine the entry site in aortic dissection. The CorCinch functional mitral regurgitation (fMR) study is a multicenter, nonrandomized, prospective early feasibility study. The objective of the study was to evaluate the safety and performance of the AccuCinch® Ventricular Repair System and assess the indices of heart failure and functional mitral regurgitation in symptomatic adult patients with mitral regurgitation and left ventricular remodeling due to dilated cardiomyopathy (ischemic or nonischemic etiology), who are of high operative risk. The AccuCinch® employs a catheter-based delivery system retrograde via the femoral artery to deliver a series of anchors into the subvalvular myocardium, using a flexible cinching cable to thereby directly reduce the basal left ventricular diameter. Procedures were performed under general anesthesia using fluoroscopy and transesophageal echocardiography guidance. Single-center data from Nebraska Heart Hospital were collected on all patients for safety, echocardiographic, and clinical outcomes as well as a subset of patients receiving a later, modified implantation technique. Longer-term follow-up data will also be presented as available. All 6 patients underwent AccuCinch implantation procedures and there were no 30-day adverse events (or serious adverse events) from this initial series. Echocardiographic follow-up was performed on all over the course of 6 months. Of the 4 patients receiving the latest implantation technique, average ejection fraction improved from 33% to 46%, left ventricular end-systolic volume decreased from 104 to 67 ml, and regurgitant volume decreased from 62 to 31 ml. Average 6-minute walk test for these patients increased from 182 to 218, while their average overall summary KCCQ quality-of-life scores improved by 14 points, from 46 to 60 points. These findings provide early feasibility data supporting the concept that a percutaneously delivered, basal left ventricular implant that cinches the myocardial wall below the mitral annulus has the potential to improve left ventricular function and reduce the severity of fMR. Surgical management of residual pulmonary regurgitation (PR) after initial repair of some congenital heart defects is truly challenging. Transcatheter pulmonary valve replacement (TPVR) is a new, less-invasive alternative to surgical valve replacement. We report the first-in-man implantation using a novel designed TPV device for patients with severe residual PR in native right ventricular outflow tract (RVOT). Patients with native RVOT and severe residual PR were selected on a case-by-case basis according to the anatomy feature of the patient and design of the valve. Patient demographics and preprocedural, intraprocedural, and follow-up data were reviewed. Four patients (2 females) with severe residual (grade 4+) were enrolled in this study with a mean age of 35.50 ± 5.67 years. Three patients had previous surgery for Tetralogy of Fallot and 1 for congenital pulmonary stenosis. All patients were symptomatic with New York Health Association heart function III at baseline. The inflow and outflow landing zone in these 4 patients was 41/39, 27/31, 27/31, and 28/30 mm, and 4 devices (44 mm/36 mm/36 mm/36 mm) were used for these patients, respectively. Successful valve implantation was achieved in all 4 patients. No device malposition, coronary obstruction, reduced flow to the pulmonary artery (PA) branches, and paravalvular leak were noted during the procedures. Mean PA diastolic pressure increased from 3.7 ± 1.5 to 16.5 ± 3.6 mmHg (p < 0.05). In 1 month follow-up, magnetic resonance imaging revealed positive right ventricular remodeling with right ventricular end-diastolic volume that decreased from 164.3 ± 5.5 to 89.8 ± 3.1 ml after intervention (p < 0.05) with the mean RVOT pressure gradient being 7 ± 0.7 mmHg. This first-in-man study demonstrates the initial safety and feasibility of the Med-Zenith PT valve in the treatment of severe PR. Dialysis-dependent patients undergoing aortic valve replacement (AVR) for aortic stenosis have poor short-term survival. Many patients who could benefit from AVR are deemed at elevated risk to undergo standard surgery. Transcatheter aortic valve replacement (TAVR) has proven to be a good option for these patients but there is little data on outcomes. Our goal was to assess morbidity and short-term mortality of dialysis-dependent patients who were deemed at elevated risk for surgery and underwent TAVR. A retrospective study of all dialysis-dependent patients undergoing TAVR over a 7-year period at 2 institutions was performed. Baseline characteristics, perioperative outcomes, and follow-up echocardiographic data were examined. Survival was determined using the Kaplan–Meier method. Variables are reported as mean ± standard deviation. Paired-samples t-test was used to determine the differences between continuous variables. Forty-seven patients, 31 (66%) of whom were male, underwent TAVR at 2 academic institutions during the 7-year period. Average age was 73.8 ± 9.1 years. Preoperative EuroScore II was 11.4% ± 8.2%. Forty-one of the 47 (87%) patients had NYHA class III or IV symptoms prior to TAVR. Twenty-six patients (55%) had peripheral vascular disease, 15/47 (32%) had chronic lung disease, and 29/47 (61%) had diabetes mellitus. Preoperative ejection fraction was 47.9% ± 16.7 %. Three patients (6%) suffered a postoperative stroke, 4 patients (9%) developed postoperative atrial fibrillation, and 2 patients (4%) had cardiac arrest. Seven patients (15%) died within 30 days. Survival at 1 and 2 years was 72% and 49%, respectively ( Figure PC67-1 ). By comparison, the 1- and 2-year survival for 237 patients on hemodialysis who underwent surgical AVR in the same time period was 64% and 55%, respectively. At a mean follow-up time of 12.1 ±11.1 months postoperatively, mean ejection fraction increased to 52.1 ± 14.1 (p = 0.016). Figure PC67-1. Survival analysis of dialysis-dependent patients who underwent transcatheter aortic valve replacement. Dialysis-dependent patients who had TAVR had poor operative and short-term survival. This was similar to patients who underwent surgical AVR. These poor short-term outcomes should temper enthusiasm for AVR, either transcatheter or surgical, in this patient population; careful patient selection is needed. A study to determine specific variables that dictate poor outcomes is warranted. Frailty is a geriatric syndrome frequently observed in elder-ly high-risk patients undergoing transcatheter aortic valve implantation (TAVI), which decreases the potential for functional recovery after TAVI and diminishes postoperative life expectancy. The study sought to develop a preprocedural frailty assessment based on parameters measured by a wearable health-monitoring device. The predictive performance of this multimodality frailty assessment (MFA) with respect to hospital mortality after TAVI was compared to conventional frailty scoring methods. A prospective cohort of elderly adults undergoing TAVI procedure via a transapical approach between December 2017 and December 2018 in a single center was included in the present study. Patients wore the device for 1 week prior to the procedure. Threshold levels in 3 categories (steps, heart rate range, and stress) were calculated with receiver operating characteristic analysis. The patients were assigned 1 point per category when exceeding the cutoff value and then classified in 4 stages (no, borderline, frail, and very frail). The MFA was then compared to gait speed category derived from 6-minute-walking-test (GSC) and the Edmonton Frailty Scale classification (EFS-C). The primary study endpoint was hospital mortality. In total, 36 patients with a mean age of 77.75 years (±5.1) were included. All-cause hospital mortality was 8.3% (n = 3). Depending on the frailty scores used, the prevalence of frailty ranged from 55.5% (MFA) and 60.6% (EFS-C) to 62.5% (GSC). Overall preprocedural stress level (p = 0.036), minutes of high stress per day (p = 0.042), minutes of rest per day (p = 0.034), and daily heart rate maximum (p = 0.036) as single parameters were the strongest predictors of hospital mortality. When comparing the different frailty scores, the MFA demonstrated the highest predictability of hospital mortality (MFA: AUC: 0.845 [0.657–1.000], p = 0.052; GSC: AUC: 0.730 [0.474–0.986], p = 0.196; EFS-C: AUC: 0.638 [0.265–1.000], p = 0.438). The preliminary findings of this study demonstrate the strong predictive performance of MFA compared to conventional frailty methods. The promising initial results warrant further evaluation of MFA as a predictor of short- and long-term mortality after transcatheter structural interventions or conventional surgery. Figure PC68-1. Comparison of the different frailty scores with ROC analysis. EFS-C: Edmonton Frailty Scale classification; MFA: multimodality frailty assessment; ROC: receiver operating characteristic. Transcatheter aortic valve replacement (TAVR) valve-in-valve (V-i-V) for homograft structural valve degeneration (SVD) is feasible, but should be implemented with caution, as the predominant homograft SVD mechanism is regurgitation. We present our concept of distributed, “aortic-to-ventricular” in-homograft fixation and outcomes of TAVR ViV for homograft vs. bioprostheses SVD. Between 2015 and 2017, 41 patients underwent TAVR ViV for the aortic valve prosthesis SVD. Of them, 33 patients presented with degenerated bioprostheses (TAVR-BP group) and 8 with homografts (TAVR-H group). The Valve Academic Research Consortium criteria were used for reporting purposes. Patients in TAVR-BP group were older (72.5 ± 15.1 years vs. 50.8 ± 16.7 years; p < 0.001) and 94% of them had prosthetic stenosis, compared to TAVR-H group (p = 0.002), while 88% of TAVR-H patients had aortic regurgitation (p ≤ 0.001). The Society of Thoracic Surgery score was 5.7% ± 3.7% in TAVR-BP vs. 1.9% ± 0.6% in TAVR-H group, p = 0.006. TAVR-H patients received Sapien-3 (6), Sapien-XT (1), and CoreValve (1) devices. Deep, 30%–40% ventricular fixation was attempted to anchor the prosthesis on the homograft suture line. In the entire cohort, there was zero 30-day mortality and stroke. One TAVR-BP patient experienced distal prosthesis migration and type-B aortic dissection, treated with immediate transcatheter endovascular aortic repair. First-attempt device implantation was successful in 26 (78%) TAVR-BP and in 7 (87%) TAVR-H patients. In 3 (9%) TAVR-BP individuals, a second device was used. No patient required pacemaker implantation. In 2 TAVR-H patients with preoperative homograft regurgitation, a moderate paravalvular leak (PVL) occurred in mid-term follow-up. In both of them, extensive, 60% ventricular fixation led to mismatch between fixation points and homograft suture line. Recent imaging revealed progressive device migration in 1 patient. There were no differences in perioperative (19.5 ± 8.9 mmHg vs. 19.1 ± 5.5 mmHg, p = 0.92) and mid-term follow-up transvalvular gradients (18.2 ± 7.5 mmHg vs. 17.9 ± 5.0 mmHg, p = 0.91) between groups. Aortic regurgitation was the predominant homograft SVD mechanism. However, lack of calcification did not cause perioperative prosthesis migration. TAVR ViV in regurgitant homograft can be safely implanted provided that the prosthesis fixation points match the homograft suture line. Precise, 30%–40% ventricular device positioning is crucial for procedural success and avoidance of PVL/late prosthesis migration. Figure PC69-1. We report a fully endoscopic implantation of a Sapien 3 transcatheter prosthesis, which was used to treat a high-risk patient with severe mitral valve disease and mitral annular calcification (MAC). This technique has all the advantages of the already reported full sternotomy transatrial technique plus the added advantage of the minimally invasive approach through a 3-cm periareolar incision and the more precise transcatheter valve placement due to the excellent stereoscopic vision available today through the three-dimensional (3D) endoscopes. A 61-year-old lady was admitted with pulmonary edema. She had a history of chronic renal failure on dialysis and aortic valve replacement with a mechanical prosthesis 4 years ago. A transesophageal echocardiography showed torrential mitral valve regurgitation because of immobile and calcified posterior leaflet and extended MAC. Preoperative computed tomography scan confirmed extensive calcification of the ascending aorta, the aortic annulus, and severe MAC, which was forming an incomplete ring. Her Society of Thoracic Surgery mortality score was calculated as 19.1%. The patient was also not a candidate for a transapical or transfemoral transcatheter mitral valve replacement due to the risk of left ventricular outflow tract obstruction (LVOT). Therefore, a hybrid endoscopic approach was offered to the patient. The chest was entered through a 3-cm right periareolar incision, in the 4th intercostal space. On full cardiopulmonary bypass, a left atriotomy was performed and the anterior mitral leaflet was excised and 3 anchoring annular sutures inserted at 12, 4, and 8 o’ clock. The annulus was sized with a 26-mm balloon and a 26-mm Sapien 3 valve was positioned and inflated under 3D endoscopic vision, with care taken that the skirt of the valve was sitting against the annulus. Then the three anchoring sutures were passed through the stent and secured. Postoperative TEE confirmed excellent function of the Sapien 3, without any paravalvular leaks or LVOT obstruction. The patient was extubated on the 2nd postoperative day and had an uneventful recovery. She remains well and in class II 8 months after her discharge with normal Sapien 3 function on echocardiogram. Acute heart failure is known to be the most frequent cause of hospital readmission after transcatheter aortic valve implantation (TAVI). Furthermore, it is associated with an increased risk of mortality. The aim of the study was to define independent predictors for acute heart failure after TAVI. From 2008 to 2017, 298 patients with isolated aortic stenosis undergoing either transfemoral or transapical TAVI were included in this single-center study. The primary study endpoint was defined as hospital readmission due to acute heart failure. All analyses were performed as time-to-first-event analysis. Stepwise multivariable Cox regression analysis was used to determine independent predictors for acute heart failure. Society of Thoracic Surgery (STS) score >4.6% (hazard ratio [HR] 2.481, 95% confidence interval [CI] 1.331–4.622, p = 0.004) and HS-Troponin T >23.3 pg/ml (HR 2.892, 95% CI 1.434–5.829, p = 0.003) were significant prognostic factors after multivariate cox regression. NT-proBNP >2,762 pg/ml (HR 1.708, 95% CI 0.909–3.208, p = 0.096) and mean gradient >45 mmHg (HR 0.661, 95% CI 0.363–1.206, p = 0.117) were significant in univariate analysis, but not in multivariate regression analysis. STS score and highly sensitive Troponin T are independent predictors for acute heart failure after TAVI. N-terminal prohormone of brain natriuretic peptide seems to be less accurate as a risk factor for heart failure after TAVI. Tetralogy of Fallot is corrected conservatively through median sternotomy universally. We have series of patients undergoing total correction for the same through minimally invasive incisions. Significant improvement in overall performance of patients in the postoperative period. In trained hands minimally invasive intracardiac repair for Tetralogy is feasible and reproducible by junior surgeons. In congenital heart disease patients, access to the pulmonary artery and pulmonary valve has traditionally been accomplished via median sternotomy or thoracotomy. Given the complex anatomy involved in congenital heart surgery and the frequent need for redo surgery, a minimally invasive approach to the pulmonary artery is desirable. We devised a minimally invasive and less-morbid surgical approach to the pulmonary artery utilizing a minithoracotomy and an innovative surgical device. Peripheral arterial cannulation and dual peripheral venous cannulation utilizing the femoral and internal jugular veins is employed. A left-sided 5 cm transverse, rib-sparing minithoracotomy is placed in either the 3rd intercostal space for pulmonary valve access or the 2nd intercostal space for distal pulmonary artery access. For pulmonary valve replacement (PVR) an automated dual-curved needle suturing device is used to place 3.5-mm-wide horizontal mattress sutures along the posterior wall, while the rest of the procedure uses hand-sewn technique and an anterior pulmonary artery polytetrafluoroethylene patch to augment the right ventricular outflow tract. Our minithoracotomy approach was initiated in July 2018 and to date has been used in 7 patients, all males so far, and ranging in age from 12 to 48 years. We have performed 4 successful PVRs, 1 PVR that was converted to an open procedure, 1 plication of the main pulmonary artery for Melody valve deployment, and 1 pulmonary artery translocation for anomalous aortic origin of the left coronary artery. Our approach provides a safe, versatile, and less-morbid method for surgically accessing the pulmonary artery and pulmonary valve. Unroofed coronary sinus syndrome (UCS), also known as coronary sinus atrial septal defect, is a rare congenital cardiac anomaly. We performed UCS repair and tricuspid annuloplasty under totally three-dimensional (3D) endoscopic vision. We utilized three-port system (1 inch main working port, camera port, and left-hand port) without robotic assistance. Both left and right atrium were entered. The UCS opening in the left atrium was closed with bovine pericardial patch. Totally 3D endoscopic repair for UCS is a safe and effective procedure. Right ventricular (RV) failure severely compromises the prognosis of many congenital heart disease (CHD) children. However, little is known about how RV failure is epigenetically regulated. Here we used CHD-associated RV failure model, neonatal rat pulmonary arterial banding (PAB), and the most common cyanotic CHD, Tetralogy of Fallot (TOF), to reveal the role of histone transferase CBP/p300 in the control of transverse tubules (T-tubules) of RV cardiomyocytes. Figure PC75-1. PAB performed on P0 significantly increased RV afterload, which induced RV hypertrophy on P7 and RV failure on P28. Compared with normal RV, RV with heart failure displayed reduced T-tubules and T-tubules-associated genes JPH2, Cav3. Calcium imaging indicated that contraction amplitude of RV cardiomyocytes significantly decreased and time to peak increased. Similar results were found in the cardiomyocytes of TOF. Lower expression of histone transferases CBP/p300 and H3K27ac were observed both in PAB-induced RV and TOF hearts. Mosaic deletion of CBP/p300 with AAV-cTnT-Cre in RV resulted in lower expression of H3K27ac in RV cardiomyocytes, loss of T-tubules and T-tubules-associated genes, and the contraction ability of cardiomyocytes. Histone transferases CBP/p300 directly regulated T-tubules of RV cardiomyocytes and its histone transferase activity plays an important role in the maintenance of T-tubules in the process of CHD RV failure development. Partial, incomplete, atrioventricular septal defect is a prevalent congenital disorder and must be researched by aiming to reach a surgical technique with minimal invasiveness and best results possible. To report the case of a 10-year-old female patient with partial defect of the atrioventricular septum, with consequent damage in the execution of their daily activities, whose correction was made by means of the surgical technique minimally invasive thoracoscopy. The ostium primum-type atrial septal defect (ASD) results from the abnormality of the cushions atrioventricular, poor embryological formation, with difficulties of anchoring the atrial septa, and may be associated with other anomalies due to defects in the cushions, such as septal leaflet fissure of the mitral valve known as a cleft as in the case in question. The therapeutic option of choice was surgical correction through the use of thoracoscopy, which enabled the procedure without direct vision and without sternotomy. The procedure was conducted with no accidents, and cardiopulmonary bypass (CPB) was conducted using a jugular, femoral, femoral cannulation and a 2 in incision posterior of the midclavicular line on the 4th intercostal space. The total CPB was 60 minutes and aortic cross-clamp 45 minutes. There was minimal blood loss and the repair of the mitral cleft was done using separate stiches and a pericardial patch for the ASD closure. The patient stayed in intensive care unit (ICU) for 18 hours and after removing the thoracic drain she was discharged to the ward. There was only 150 ml of drainage volume. On the 3rd postoperative day she was discharged home. She was cleared to all her normal activities without any restriction on postoperative day 10. This technique permits less aggression to the patient, allowing in some cases extubation of the patient still inside the operating room, right before being referred to ICU, known as FAST TRACK. In addition to that are a notably lower inflammatory response, lower intra- and postoperative bleeding, with consequent reduction of ICU and hospital length of stay. To evaluate the early results of totally endoscopic closure of ventricular septal defect (VSD) in Vietnam. Totally endoscopic VSD closure was performed in 8 patients (3 children and 5 adults). All patients were diagnosed with perimembranous VSD in which 5 patients had right ventricular outflow tract stenosis. We used 3 trocarts of 5 mm and 1 trocart of 12 mm in the right chest, using peripheral cannulation for cardiopulmonary bypass, bicaval occlusion, Chitwood aortic clamp, right atriotomy, and closing VSD by endoscopy without a robotically assisted surgical system. No postoperative complications and deaths. Mean ± standard deviation of cardiopulmonary bypass time and aortic clamping time were 70 ± 23.6 and 50.6 ± 25.3 minutes. The mean mechanical ventilation time was 1.2 ± 0.3 hours. Patients were hospitalized for 5.8 days and could resume normal activities after 1 week. Totally endoscopic closure of VSD without robotic assistance is feasible and safe, with a small surgical scar and high esthetics. Myo-myectomy for hypertrophic obstructive cardiomyopathy (HOCM) through aortic valve had limitations such as limited operative view, risk of aortic valve damage, and insufficient muscle resection. Via left atrial (transmitral) approach can provide an opportunity for mitral valve repair/replacement for mitral regurgitation. Six patients (6–73 years old) had myo-myectomy for diffuse subaortic obstruction of HOCM with our approach. Three had mitral valve repair and 3 had mitral valve replacement. Every case had relief of obstruction and symptom (left ventricular outflow tract gradient; 5~26 mmHg). Our approach could provide a wide view of subaortic region and lower portion of the septum and adequate operative view for those with diffuse type of HOCM. Figure PC78-1. Myo-mectomy for subaortic obstruction through mitral annulus. The purpose of this study was to evaluate the safety and efficacy of direct intralesional diode laser vaporization for venous malformations (VMs) with oroparyngeal involvement after a temporary tracheotomy. A retrospective assessment was carried out to evaluate the efficacy of direct intralesional diode laser vaporization on 21 consecutive patients presenting with extensive VMs involving the oropharynx in the head and neck and who had undergone tracheotomy. Of the 21 patients, 4 were treated once and 17 were treated from 2 to 5 times. The duration of follow-up was, on average, 9.1 months. Of the 21 patients, 11 (53.3%) had complete palliation, whereas the rest (46.7%) achieved partial palliation. Minor complications occurred in 12 of the 21 patients. Direct intralesional diode laser vaporization after a temporary tracheotomy is a safe and effective treatment for extensive VMs involving oropharyngeal areas of the head and neck.