 Thank you. I promise you in the interest of time, I didn't move fast. And it is a, my topic is robotic coronary, robotic assisted cardiac surgery. This is a very exciting emerging technology field. And we have seen a lot of progress in recent years, especially in cardiac surgery. Interestingly enough, the history has been, the cardiac surgery has been tied with the profusion. And the real takeoff of cardiac surgery started with the invention of cardiac pulmonary bypass. This is the earlier picture that was taken in the University of Minnesota, that when the first devolved Leatherhike cardiac pulmonary bypass machine was used first time in the pediatric surgery and also in cardiac surgery. In this picture, and interestingly enough, a lot of Dr. Cooley went down to Minnesota University many times to visit the surgery and the cardiac surgery and then came back to Houston and then he actually drafts an abstract that is displayed in the baking museum that he says how to build a cardiac pulmonary bypass machine. And then that's the beginning of the Texas heart cardiac pulmonary bypass program. And then that's never leading the future and push the cardiac surgery to a new height. So with this 60 years forward now at Baylor College Medicine at the St. Luke's Hospital now, this is the daily routine we're doing the cardiac surgery using the robot and the venture robot. Then we do about two cases a day, back to back every day and in this hospital. This is the, we started the program ever since I joined this great place. I was trained in the state of the University of Minnesota in my first career and then I joined here in 2019. And the great institution that we started the robotic program here right at get going. So now today we have done over 350 robotic heart surgeries and already and mostly the robotic mitral valve repair and also complex robotic coronary artery bypass. And the now looking back and currently robotic surgery is about 75% of my practice. And basically robotic surgery is majority of my practice compared to the other open heart surgeries. I see the train of this getting more and more minimally invasive smaller and smaller institution and they use more and more technology to move the whole field as we can see the development of robotic surgery developed is over the past 20 years. And then there are three generation robotic devices have been developed the first generation is made mainly from 1999 to 2006 as first generation second generation is developed between 2006 and 2009. The third generation is more recent from 2014 to 2017. The initial robotic machine was designed for the use of cardiac use and developed for operating to assist the surgery is inside the Sorax because Sorax is the bonus structure is rigid it's difficult to to get to you want to get to you have the open heart surgery and anatomy and then that's major invasive. So the concept of developing robots through the robotic instruments to piece through the rope into coastal spaces you can operate inside a rigid cage. That's the initial design of the robot but unfortunately the first generation of robot is very difficult to use. That's why most cardiac centers abandoned the use of the robot, and then you went to the urology become major adapter of the robotic surgery robotic prostatectomy and then subsequently followed by the takeoff in GYN surgery. Now it was this current generation of robot, and then there's a momentum now in cardiac surgery practice now the robotic assisted cardiac surgery and now it's retake taking off again and as showed in the ways seen in this institution that just want to give you a brief of brief overlook of technology part of this robotic technology especially used in the cardiac surgery. So, basically, if you look at most of commonly prepped perform the cardiac surgery procedures can be performed safely and routinely in by the robotic technique, all this list of procedures are down here on the data routine at this institution that there's a nooks hospital. But if you look at the frequency of the surgery is the most common you perform the robotic surgery is a mitral valve repair check out the valve repair and follow the back cornering artery bypass drops in surgery. And you can see the technology is powered by the state of the robot technology, and then there's a 3D computer console the surgeon is used to control the arm movement, and then the robot is connected through the cable to the patient's bedside with four arms of robot and then there's a bedside assistant surgeon responsible for exchange the instruments and then to provide us appropriate and the assistant and through a working port. And as I said forms and their form it's been controlled by finger tip control by the surgeons and the motion scale actually the tremor can be filtered through the, the by the machine if the surgeon's hands are shaking if you drink too much coffee doesn't matter is that would not impact the robotic instrument there's a way of filtering out the, the tremor, and this works well for the senior surgeon when they get old cannot stand too long hours to sit down they sip up coffee and then operating on the machine. And I find it's amazing I used to stand hours operating my, at the end of the day I made my back hurts neck hurts. Now I find itself 50% of time I stand ship because and I sit down, which is great and it's a great combination. I can see with more technology you can become a remote operating tools in the future. The visualization of the robot is unbelievable, I think you invite you to go to the or to take a look. But if I imagine a show here that cannot be matched or imagine so do you see through the scope is a truly magnified and the 3D panoramic view of the aesthetic of yours that nothing can match you see so well of everything. And then the instrument is very tiny, the tip of instrument is, as you can see a few millimeters with the tip of needle holder and grasper, we call the micro grasper and then the the suturing cutting scissors. Very precise movement and also the design is such that you control the instruments right in front of your eyes. And you almost like you're operating in front of your eyes. That's the beauty of this layout. Why robotics and then that would be good. Everybody else we've been doing this open heart surgery for many years we're doing the same way all the time. But there's a reason why we there's an opportunity can we we can improve to do robot if you look at the typical three vessel primary artery bypass surgery. We typically use the limit you already the most important bypass graph this is the native artery from your chest wall supply the breastbone on the left side, there's another artery on the right side right internal memory artery. And then we use the rest of the graph and use the vein graph. So, the, in order to do this surgery, and then of course there's many studies show why, why, what's the, the benefits compared to the open heart surgery bypass compared to the standing. And you turned out the benefits mostly happen in the diabetic patient, because in the bypass graph patient that is the graph patencies remains much higher, and then the outcome is much better versus in the diabetic patient. And if you get a stance, your overall longevity or survival is much lower even though upfront, and that the invasive this is less, but your survival long term survival is much poor compared to the bypass graph and surgery. The main benefit of bypass bombing studio is that long term patency rate of left internal memory artery at your graph to bypass the most important target of vessel left into a distance the artery. And the stage opened over 15 years at 90% of the time or higher patents. That's the reason the benefit the sole benefit of open heart surgery. And so there's one single most important graph. This is the graph that we take it dissect it out you keep the proximal origin at the inside show practical graph. And then this gives the blood supply to the heart. In order, unfortunately, the old techniques in order to harvest this artery, we need to open the chest, we need to use electric cord array to detach this artery from the chess wall to use it. And that's the end you can see this open heart surgery is getting complicated. You have the vibe at your Canada, you have Venus Canada, and the big open world. And sometimes that certain patients with pathology, especially a senior order calcification and severe vascular disease, and you cannot do the kind of primary bypass circuit you cannot insert circuit you have to rely on the beating heart and surgery without any instrumentation can elation to the order or what existed. So that this comes to the minimum invasive robotic bypass and advantage of using the robotic technique to harvest the left internal memory artery, without open the chest, without open the story economy. So the video through the robotic instruments to harvest the memory on the left side, sometimes you can harvest the memory from the right side if you need to do multiple bypass grafting. Now that with technology we can pinpoint exactly where is the left internal memory on the way is the right internal memory artery and over the target vessel so we need to open up the making the incision to attach the artery to the coronary artery and through which in the process with everything is planned very well ahead of time use this technology so they can minimize the incision you made on the patient. I give you the sample of the cartoon how we can relate this patients in the chest can three ports location position, and the typical in the third fifth and seventh across the space. And then this is the camera port is in the middle and the instrument port is the upper third in the coastal and the grasp report is the seventh in the coastal space. As you can see now the, the, the, once we enter the chest with inspect left internal memory artery quickly. And they find the course, the artery and he get ready to harvest the artery, and then usually like to coordinate the first, open up the fashion layer and find the internal memory artery. And then use the, the small micro vessel clip, this is only about one or two millimeter size this is a mechanism by view, but clip in the coastal space, and then divided all the branches and then the, and then take the, take the entire lens of the memory artery from the chess wall, and the mobile is it, and they keep the proximal origin intact. Open the pericardial and find the target segment of the bypass, the target LAD, and everything is done through beating heart without hotline machine. And as you can see we identify the target segment. And then once it's identified we find the corresponding in the coastal space, putting a needle through with located this is the target area and then this is in the coastal space to put a needle through it. And then there's four incision typically about one to two inch incision, and then prepare that this end of the Lima graph would get ready for bypass great flow after the harvesting and then is a stabilizing device that's used to temporarily in the local area to stabilize the target vessel and replace a pair of elastic tapes to temporarily accrue the vessel and make our to me, and then insert it into corner is shunt inside. So the heart is beating in this particular area that heart is not moving much. So it's relatively still, you can do a nice and estimate it. Meanwhile, you have a shunt inside and then that protects the social from catching the back wall, but also this shunt maintains the flow in the artery during the bypass surgery. And then that's why how we do the direct sewing in that area, the other is not moving. We open up the artery and then put a shunt inside. And that, yeah, this is just so everything is done precisely through a small one to two inch incision, and then put a shunt inside. And then we bring the bypass. So the artery directly in the beating heart, and then from one side to to attach to together. Right before we tie in the future, we take out the shunt, and then tie the future. And this is the final stage in the end. So that's, this, the give you give us a specialty to have minimal impact on the heart without ischemic without arresting the heart, and with minimal, minimal blood loss. So this is the institution, typical institution after surgery is done, and patients return to work is very fast. And within three weeks, four weeks, you can do push ups without any concern without the sternum precaution. It was totally changed the way how we do the open heart surgery. And then then the patients return the functional recovery is much quicker. And then the chance of the risk of stroke, which is typically associated with cardiovascular bypass circuit is totally associated patient like high risk patient with the stroke risk, this will work out the best this kind of procedure, and we can follow the patients graph long term patients rate with CT scan. So we further recently advanced the field by using the peripheral ECMO in extremely high risk patient in those patients who are previously cannot consider a candidate for robotic surgery or even open heart surgery or any standing with peripheral ECMO to stabilize the patient. And then we do the, we do the beating heart, and the instruments with new materiality is worked out beautifully and then we presented this paper in the meeting and this recently published, and this would lead the future evolution of robotic surgery and then technology, even with the ECMO technology. Another example of using the wire with technology is very important. And there is in the field of mitral valve surgery mitral valve prolapse is a very common disease affects two to 3% of general population the most common ones the prolapse type two prolapse procedure leaflets which is called the frail segment severe mitral regurgitation. So how we do this in the old days on the technology is surgery is very straightforward you do a wedge resection of this procedure segment. It mobilizes the surrounding leaflets to cover the defect and put a band there. This is the surgery 80% of procedure of mitral valve is done, but unfortunately it's been done. This is the old way, it's very difficult to see, and the heart basically, as you can see this is the old way of doing this conventional way big opening procedure lift heart or rotate heart to see the valve because valve mitral valve is sitting behind the heart in order to see it to flip over the heart and the anatomy is totally screwed. It's not easy to get do a good repair that's why the mitral valve surgery you have to send it to a high volume center high volume surgeon to do it doing right. And there's a reason that because the whole anatomy totally screwed. And then so that the robot is taking one technique that it will change the start because robot will maintain the heart position to do the most physiological location position the heart. So you can do a much precise repair I'll see I'll show you why. You can see this valves mitral valve when you open the sternum. This is what you show our water pulmonary artery, right ventricle right ventricle is in the front if you look at from the short section mitral valve is here, and the order that's the pulmonary artery. So in order to get here this mitral valve is sitting way behind it, going to the front to see the mitral valve you have to rotate a whole heart flip over, which sometimes can be difficult, especially in the hypertrophy part. And the patient had previous surgery. It's very difficult they set to rotate to see the heart. For the robot, the setup is like this you go from the side laterally, you have a straight shot to the visualization mitral valve use peripheral cardiac pulmonary bypass circuit for the one female vein female artery cannulation occasioning So the IJ right IJ is busy drainage. And then this is how the institution was made with the robotic instruments on the upper and the lower instruments and then retract them and then walking towards through this area. This is how we set it up. Visualization basically we see the valve right there when the camera zoom in and put the sutures through the mitral and this is a big prolapse segment. And the mitral the needle position so precise in this with robot technique, as you can see, that is much precise, especially difficult angle there in the corner area in the very tiny space. But it's because you have this five millimeter needle to make it difficult, make it much easier to put in the suture in a good in a difficult position, and very precisely and then the scissors you can cut it out. Everything is making magnified through this robot, you can see everything so well cut this redundant prolapse segment, and then repair the, the, and then cut it out. Yeah. And then, once it's cut it out, you put sutures bring the surrounding leaf is together to cover the defect. And then this is sold through the suture we can do a two layer continuous running suture. And then at the end we tie the suture. So the suture is tied. Now we, now we bring the size up to size the ring, we're going to put it in. Then we put rain inside inserted down. Then we tie the sutures with automatic not tying device. Now we'll see how the valve looks like repair looks perfect watertight. It is no leak. And then you can see everything in an anatomic position physiological position it didn't rotate hard it didn't flip the heart the heart you want to test it much easier to test more real time assess the repair result. And then we can do a lot of other procedures such as maze procedure ablation procedure. At the same time this is a choir maze application to the primary veins to block the acid. And then we can do this is another application of the choir maze. And then we can do the close left each in appendage through the robot as well and the close the pouch there. Everything starts with the robot from inside a small chamber opening them. Once it's done it many ways are different ways it's like this file that we see the certain we can test about one little pressure at a given time. And then we can very precisely know where is the pathology how to repair it. So this patient is repaired. So the additional stitch of the Fisher close the Fisher between the two leaflets. How does it look like, and then this one is a testing again about looks the beautifully watertight so the priest, the repair is much more precise and the highest rate of success repair. In the robotic technique compare compare to the open technique. So the institution at the end is like this, and it's tiny quarter incision, and then in the one to two inch incision and then lateral wall of the chest. And the costumatically it's very appealing to many people and also the rehab recovery physical rehab and the blood loss, and everything is really changed the difference that the perspective of the cottage. So not what I want to show you one condition is very difficult to treat is a very heavy calcified Mac severe mitra standards with heavy calcification. So we use the robot technique together with transcasseter technique, and then to to perform the surgery for this difficult situation, as you can see this patient also very difficult calcified normally would consider country indicated in surgery because too much calcium. And the patient would not do well and if you take out calcium and to to do the surgery so but then we have the actually we just reported our largest series in the whole country, using this technique to do the difficult surgery that turned down for open heart surgery, sometimes the only option the left is to send to here to reject the calcium the brilliant, and then we put a tab above through the transition approach using the robot truly use the minimum invasive way to use this, the state of art technology of robot combined with transcasseter technique. So once this, the, sorry. The, once the valve is rejected with fashion be the size and then measure the size with the balloon. This is the use typically in the Tava about transcasseter about we use that directed with the robot and then we'll put about three as framed about in this balloon with the with the felt strips to cushion the parabolic space and then deployed on the direct vision with the robot assistant, you can see proceed can very clearly I find ideal landing zone and then, and then deploy the valve. Once the valve is deployed and then we have this anchoring sutures to further stitch to the frame of this Tava valve the frame so the valve doesn't migrate sometimes in the Tava valve is concerned whether this valve with the migrate or not, but in this case, once we deploy we have additional we can touch them and we can anchor it and then we test about both is very competent. So this is a technology that we and reported recently in the this year's ATS meeting as one of the new technologies and leading potential change the field in this area to to treat a very difficult pathology in this area. So we just stay stop here by that overall the the technology is stay here to stay and you'll see more and more people started using this and will also will will in this some in this fall, we're going to start organizing the teaching course in this institution to train the fellows to work on the other part of the country. I just want to thank you thank the the profusion school symposium for the opportunity to present our work.