1. The Future of Minimally Invasive Cardiac Surgery Marco A. Zenati, M.D. Professor of Surgery and Bioengineering University of Pittsburgh School of Medicine

3. Hans Jacobeus Pioneer of Thoracoscopy (Stockholm 1910) Modified Cystoscope Jacobeus HC. The Cauterization of Adhesions in Pneumothorax Treatment of Tuberculosis. Surg Gynecol Obster 1921:32:493-500 (40 patients)

4. Thoracic Endoscopy Pioneers in Pittsburgh 1993 - Landreneau Luketich

5. From MIDCAB to TECAB

6. Dexterity Enhancement

7. “Intuitive” Surgery: Can You Beat a Fifth Grader?

8. Computer Motion’s ZEUS 1999-2002 Intuitive Surgical’s DaVinci 2004- Robotic Surgery in Pittsburgh

9. April 5 th, 2001 University of Pittsburgh Medical Center First U.S. Robotic Off-Pump CABG Cardiac Surgeon: Marco A. Zenati, M.D. Patient: 63 yo JAC Day of discharge home: April 8 th, 2001 POD#2

10. Level 4 MIS for MVR

12. “Ideal” Minimally Invasive Surgical Procedure  Single Port  Access ANYWHERE  Local vs General Anesthesia  No need for unnecessary invasion of pleural spaces  Minimize pain NEJM 2006;354:20

15. MIS Tools Constrained to Pivot at the Body Entry Point

16. The New York Times May 2007 HEARTLANDER

17. HeartLander

18. Bilateral VATS for Pulmonary Vein Isolation in AF

19. SUBXIPHOID ACCESS

21. Patient-Specific Strategy for AF

22. Ganglionated Plexi Armour Anat Record 1997

23. Rigid Endoscope and Instrument Arm Shaft Rigid Endoscope and Instrument Arm Shaft –Unable to navigate complex 3D geometry spaces (e.g. pericardial space)

26. Ann Thorac Surg 2007

29. LAA RAA Through Transverse Sinus Entry point: Subxiphoid

30. RSS Design -Current Prototype-

32. Cardiac SurgeonCardiac Electrophysiologist Direct Endoscopic SVP Visualization Fluoroscopy Continuous EKG and hemodynamic monitoring NAVx 3D Imaging StJude Med HYBRID INTERVENTIONAL SUITE

33. Subxiphoid Approach

34. Myocor COAPSYS

35. Common Lesion Sets Employed in AF Ablation

36. Cox-Maze IV

37. Future Clinical “Battlefields”  Heart Failure –Ischemic Mitral Regurgitation –Prevention of Remodeling after MI  Atrial Fibrillation

39. 8 Fr. catheter with an irrigated radiofrequency tip (Biosense Webster) 60ºC, 40 watt, 15 seconds × several times Ablation procedure Pathway Closed Chest Epicardial Ablation

40. Subxiphoid Videopericardioscopy for CRT Lead Zenati et al. Circulation 2002

41. Epicardial Lead Placement for CRT with DaVinci Robotic System