Da Vinci Robot-assisted Beating-Heart vs. Cardioplegic Arrest Atrial Septal Defect Repair: A Clinical Comparison of Feasibility and Outcomes

Da Vinci Robot-assisted Beating-Heart vs. Cardioplegic Arrest Atrial Septal Defect Repair: A Clinical Comparison of Feasibility and Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Da Vinci Robot-assisted Beating-Heart vs. Cardioplegic Arrest Atrial Septal Defect Repair: A Clinical Comparison of Feasibility and Outcomes Qingjiang Wang, Rui Dai, Wei Wang, Haoyan Li, Xun Chi, Ziang Sun, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7961339/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Da Vinci robot-assisted cardiac surgery has emerged as an indispensable modality in minimally invasive cardiac surgery. This study aimed to compare the clinical outcomes of Da Vinci robot-assisted atrial septal defect (ASD) repair under beating-heart versus cardioplegic arrest conditions. Methods A retrospective cohort study was conducted on consecutive patients who underwent Da Vinci robot-assisted ASD repair at our institution from November 2014 to April 2024. Patients were stratified into two groups on the basis of the surgical approach: the cardioplegia arrest group ( n = 23) and the beating-heart group ( n = 75). General clinical data, perioperative parameters, postoperative recovery metrics, and early clinical outcomes were compared between the groups. Results A total of 114 patients underwent successful Da Vinci robot-assisted ASD repair, with no perioperative or 30-day mortality. Compared with the cardioplegic arrest group (n = 23), the beating-heart group (n = 75) presented a significantly shorter cardiopulmonary bypass (CPB) time (81.07 ± 20.95 min vs. 149.87 ± 50.50 min, P < 0.001), and eliminated aortic cross-clamping (0 ± 0 min vs. 71.43 ± 24.45 min, P < 0.001). The operative time was significantly shorter in the beating-heart group [200 (180–240) min vs. 260 (230–300) min, P < 0.001]. Postoperatively, the beating-heart group required less mechanical ventilation [11 (8–14) h vs. 15 (12–20) h, P = 0.001], had a lower 24-hour drainage volume [120 (70–200) mL vs. 230 (160–330) mL, P < 0.001], and had a shorter intensive care unit (ICU) stay [66 (42–80) h vs. 87 (63–94) h, P = 0.018]. Complication rates were comparable between the groups, with no residual shunts or severe arrhythmias. Conclusion Da Vinci robot-assisted beating-heart ASD repair is safe and feasible, avoids aortic cross-clamping-related risks, significantly reduces the CPB time, and offers postoperative recovery advantages. Figures Figure 1 Figure 2 Introduction Atrial septal defect (ASD) is the most prevalent congenital heart disease (CHD) in adults, accounting for 25–30% of new diagnoses [1]. Secundum ASD is the most common anatomical subtype, followed by primary, sinus venosus, and coronary sinus defects [2,3]. Transcatheter closure is the preferred approach for eligible patients [4], whereas surgical repair remains the mainstay for defects with deficient rims, excessive size, multifenestration, failed catheter closure, or concomitant intracardiac anomalies [5]. Table 1 baseline characteristics of the patients Cardioplegic Arrest group ( n =23) Beating-Heart group ( n =75) p value Age （years） 43.87 ± 16.08 38.28 ± 16.87 0.163 male gender, n (%) 11 (47.8) 53 (70.7) 0.101 BMI (kg/m 2 ) 23.60 ± 3.02 23.46 ± 4.50 0.884 NYHA class 0.686 I 6 (26.1) 29 (38.7) II 15 (65.2) 33 (44.0) III 2 (8.7) 13 (17.3) IV 0 (0) 0 (0) Comorbidities, n (%) First - degree Atrioventricular Block or Right Bundle - Branch Block 4 (17.4) 18 (24.0) 0.506 Atrial Fibrillation 0 (0) 8 (10.7) 0.192 Coronary Heart Disease 1 (4.3) 2 (2.7) 0.556 Hypertension 5 (21.7) 8 (10.7) 0.177 Diabetes mellitus 1 (4.3) 1 (1.3) 0.416 Cerebrovascular disease 0 (0) 4 (5.3) 0.570 Echocardiographic data ASD size (mm) 2.73 ± 0.96 2.62 ± 0.80 0.593 LVEF (%) 62 (60–64) 62 (60–63) 0.818 Pulmonary artery pressure(mmHg) 45 (39–65) 45 (40–52) 0.798 BMI: Body Mass Index, NYHA: New York Heart Association, ASD: Atrial Septal Defect, LVEF: Left Ventricular Ejection Fraction The Da Vinci robot-assisted ASD repair has been widely accepted as a safe and effective minimally invasive alternative [6]. However, technical complexities (e.g., intracorporeal knot tying) and steep learning curves have constrained its widespread adoption [7]. To address these issues, we optimized the surgical protocol to facilitate beating-heart ASD repair. Since November 2014, our institution has performed 560 Da Vinci robot-assisted procedures, including 98 ASD repairs. This retrospective study compared the outcomes of robot-assisted ASD repair with and without cardioplegia to validate the advantages of beating-heart surgery. Methods Human Ethics and Consent to Participate declarations: This study was approved by the institutional review board of The Affiliated Hospital of Qingdao University (Approval number QYFY WZLL 30733). Since the study was a retrospective study, informed consent was waived by the Ethics Committee. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Clinical trial number: not applicable. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Patient Selection and Grouping Patients were preoperatively diagnosed with ASD via transthoracic echocardiography, which evaluated the defect type, size, left ventricular ejection fraction (LVEF), and pulmonary artery pressure. Patients aged ≥50 years underwent coronary angiography to exclude concomitant coronary artery disease. Exclusion criteria included the requirement for complex cardiac surgeries. The inclusion criteria were as follows: (1) body weight >40 kg; (2) no thoracic disease/surgery causing right thoracic adhesions; and (3) no aortic aneurysm or femoral arteriovenous malformation. From November 2014 to April 2024, 98 patients underwent the Da Vinci robot-assisted ASD repair at our hospital. They were divided into Group 1 (23 cases, cardioplegia arrest repair with aortic cross-clamping) and Group 2 (75 cases, beating-heart repair). Preoperative characteristics ( Table 1 ) were comparable between the groups in terms of age, sex, body mass index (BMI), New York Heart Association (NYHA) class, LVEF, and pulmonary artery pressure. Surgical procedures All patients underwent general anesthesia with double-lumen tracheal intubation and selective left lung ventilation. Transesophageal echocardiography (TEE) and arterial pressure monitoring were performed. A central venous catheter was inserted into the right internal jugular vein, together with a 16-Fr venous cannula for superior vena cava drainage. External defibrillator pads were positioned on the right shoulder-back and cardiac apex. Patients were placed in a supine position with the right chest elevated 15–25° and the right arm adducted ( Fig. 1 ). Under selective left lung ventilation, a 1-cm incision was made at the fourth intercostal space midclavicular line for endoscopic exploration. If unremarkable, the incision was extended to 3–5 cm as the main working/endoscope port. Following systemic heparinization, cannulation via the femoral artery/vein initiates cardiopulmonary bypass (CPB). Five-millimeter incisions at the third, fifth, and sixth intercostal spaces were created for the robotic arms and the atrial retractor ( Fig. 2 ). The pericardium was incised ≥2 cm from the phrenic nerve, exposing the aorta and vena cava, with snares placed around the vena cava. Cardioplegia group Purse-string sutures were placed at the aortic root for cardioplegia catheter insertion. A chain clamp was used to occlude the ascending aorta, followed by cardioplegia infusion. After cardioplegia arrest, the vena cava was clamped, and the right atrium was incised via the robot. The ASD was exposed with retractors, and direct suture or patch repair was performed. Before suturing, the left lung was inflated to evacuate the air. The aortic clamp was released, and after the heart resumed beating, the right atrium was closed. The root catheter was removed after deairing, and purse-string sutures were tied. Beating- Heart Group The vena cava was clamped, respiration was paused, and the right atrium was incised while the heart beat. An intracardiac suction device aspirates blood to expose the ASD, which is repaired by direct suture or a patch. Left lung inflation before suture tying ensured air evacuation. The right atrium was closed with a double-layer 4–0 Prolene suture. After unclamping the vena cava, TEE confirmed the integrity of the ASD closure. Following CPB weaning, the femoral venous cannula was removed. The superior vena cava cannula was heparin flush, clamped, and removed in the ICU. A chest drain was placed via the sixth intercostal incision. Statistical analysis The Shapiro‒Wilk test was used to verify the normal distribution of continuous variables, which are expressed as the mean ± standard deviation and were compared via Student’s t- test. Nonnormally distributed variables are expressed as medians [interquartile ranges (IQRs)] and were compared with the Mann‒Whitney U test. Categorical variables are expressed as frequencies (%) and were compared with the chi-square test or Fisher’s exact test. Propensity score matching was unnecessary because of comparable baseline characteristics. Analyses were performed via SPSS 26.0, with P < 0.05 considered statistically significant. Table 2 Intraoperative data of the patients Cardioplegic Arrest group ( n =23) Beating-Heart group ( n =75) p value Operation time (min) 260 (230–300) 200 (180–240) <0.001 CPB time (min) 149.87 ± 50.50 81.07 ± 20.95 <0.001 Aortic cross-clamp time (min) 71.43 ± 24.45 0 ± 0 <0.001 ASD closure 0.144 Primary closure, n (%) 21 (91.3) 56 (74.7) Patch closure, n (%) 2 (8.7) 19 (25.4) RBC transfusion (U) 0 (0–1.5) 0 (0–0) 0.056 Sternotomy conversion, n (%) 0 (0–0) 0 (0–0) CPB: Cardiopulmonary Bypass, ASD: Atrial Septal Defect, RBC: Red Blood Cell Results All procedures were performed by the same surgeon, with successful ASD repair in both groups and no perioperative or 30-day mortality. No conversion to minoracotomy/sternotomy was needed, and no device-related complications occurred. Table 3 Postoperative data of the patients Cardioplegic Arrest group ( n =23) Beating-Heart group ( n =75) p value mechanical ventilation time (h) 15 (12–20) 11 (8–14) 0.001 Postoperative 24-hour drainage volume (mL) 230 (160–330) 120 (70–200) <0.001 Length of ICU stay (h) 87 (63–94) 66 (42–80) 0.018 postoperative hospital stay (d) 11 (9–14) 9 (8–11) 0.013 RBC transfusion (u) 0 (0–0) 0 (0–0) 0.204 Early mortality, n (%) 0 (0–0) 0 (0–0) Complications, n (%) Residual atrial septal defect shunt 0 (0) 1 (1.3) 1.000 Re-exploration for bleeding 1 (4.3) 1 (1.3) 0.416 New stroke 1 (4.3) 0 0.235 New onset atrial fibrillation 3 (13) 4 (5.3) 0.350 Postoperative surgical site infection 0 (0) 3 (4.0) 1.000 Ventricular premature beats 2 (8.7) 1 (1.3) 0.136 Pericardial effusion 0 (0) 1 (1.3) 1.000 Second cardiopulmonary bypass 1 (4.3) 0 0.235 Pulmonary infection 3 (13) 2 (2.7) 0.083 Liver dysfunction 1 (4.3) 1 (1.3) 0.416 Pneumothorax 1 (4.3) 1 (1.3) 0.416 Lower extremity vascular 1 (4.3) 0 (0) 0.235 Hospital readmission, n (%) 1 (4.3) 4 (5.3) 1.000 30 - day mortality 0 (0) 0 (0) Echocardiographic data LVEF (%) 62 (61–63) 61 (60–63) 0.283 Pulmonary artery pressure(mmHg) 28 (25–34) 30 (25–34) 0.940 1-month post-operative Echocardiographic data LVEF (%) 62 (60–64) 62 (60–63) 0.275 Pulmonary artery pressure(mmHg) 24 (20–32) 28 (23–31) 0.151 ICU: Intensive Care Unit , ASD: Atrial Septal Defect, LVEF: Left Ventricular Ejection Fraction Table 4 Test statistics for changes in LVEF and pulmonary artery pressure a LVEF - Postoperative LVEF Postoperative LVEF - 1-month post-operative LVEF Pulmonary artery pressure - Postoperative pulmonary artery pressure Postoperative pulmonary artery pressure - 1-month post-operative pulmonary artery pressure Z -0.763 b -0.209 b -8.151 b -2.122 b P 0.445 0.835 <0.001 0.034 a: Wilcoxon Signed Ranks Test b: Based on negative ranks. LVEF: Left Ventricular Ejection Fraction The beating-heart group presented significantly shorter operation times [200 (180–240) min vs. 260 (230–300) min, P < 0.001], CPB times (81.07 ± 20.95 min vs. 149.87 ± 50.50 min, P < 0.001), and aortic cross-clamp times (0 ± 0 min vs. 71.43 ± 24.45 min, P < 0.001) ( Table 2 ). The ASD patch repair rate was 91.3% in the cardioplegia arrest group and 74.7% in the beating-heart group (P = 0.144), whereas red blood cell transfusion rates did not differ significantly (P = 0.056). Table 5 Test statistics for group comparisons of LVEF and pulmonary artery pressure changes c Postoperative LVEF - LVEF 1-month post-operative LVEF - Postoperative LVEF Postoperative pulmonary artery pressure - Pulmonary artery pressure 1-month post-operative pulmonary artery pressure - Postoperative pulmonary artery pressure Z -0.391 -0.533 -0.268 -1.671 P 0.696 0.594 0.788 0.095 c : Grouping Variable: Cardioplegic arrest group=0, Beating-heart group=1 LVEF: Left Ventricular Ejection Fraction Pulmonary artery pressure decreased significantly from baseline to postoperative (Z = −8.151, P 0.05) ( Table 4 ). The group comparisons revealed no significant interactions over time (P > 0.05), indicating similar trend trajectories ( Table 5 ). Discussion Atrial septal defect (ASD) represents a common congenital cardiac anomaly that, if left untreated, may progress to severe complications such as pulmonary hypertension—particularly in patients with large or symptomatic defects [8]. While traditional open-heart surgery remains the gold standard for complex ASDs [9], the Da Vinci Surgical System has emerged as a viable minimally invasive alternative [10]. Its technical advantages—including three-dimensional stereoscopic visualization and robotic arms with seven degrees of freedom—afford substantial clinical benefits, such as reduced surgical trauma and accelerated postoperative recovery [11]. Two primary strategies dominate Da Vinci-assisted ASD repair. The conventional cardioplegic arrest technique, which relies on cardiopulmonary bypass (CPB) to create a static surgical field, has a well-documented safety profile [12,13]. In contrast, the emerging beating-heart technique maintains continuous cardiac contraction, thereby eliminating myocardial ischemia-reperfusion injury [12]. This approach offers distinct advantages: shorter CPB duration, reduced embolism risk, and preservation of electrophysiological stability. Clinically, the beating-heart technique has demonstrated superiority in myocardial protection, coagulation function preservation, and postoperative complication reduction, establishing it as an innovative modality for minimally invasive ASD repair [6]. Our findings demonstrated that the beating-heart group exhibited significantly greater surgical efficiency than did the cardioplegia arrest group. The median operative time was substantially shorter in the beating-heart cohort [200 (180–240) min vs. 260 (230–300) min, P < 0.001], accompanied by a 46% reduction in the mean CPB time (81.07 ± 20.95 min vs. 149.87 ± 50.50 min, P < 0.001) and complete elimination of aortic cross-clamping (0±0 min vs. 71.43 ± 24.45 min, P < 0.001). Postoperative recovery metrics were also markedly improved in the beating-heart group. Patients in this cohort had a 27% shorter median mechanical ventilation duration [11 (8–14) h vs. 15 (12–20) h, P = 0.001], a 48% lower median 24-hour chest drainage volume [120 (70–200) mL vs. 230 (160–330) mL, P < 0.001], and shorter stays in both the ICU stay [66 (42–80) h vs. 87 (63–94) h, P = 0.018] and postoperative hospital stay [9 (8–11) d vs. 11 (9–14) d, P = 0.013], resulting in an 18% shorter overall hospitalization. In terms of adverse events, while the incidence rates of pulmonary infection (2.7% vs. 13.0%, P = 0.083) and ventricular premature beats (1.3% vs. 8.7%, P = 0.136) were significantly lower in the beating-heart group than in the control group, these differences did not reach statistical significance. Both groups showed significant improvement in postoperative pulmonary artery pressure (P 0.05). These findings highlight the benefits of avoiding aortic cross-clamping and shortening the duration of CPB, which effectively reduces the risks of a systemic inflammatory response and coagulation dysfunction associated with prolonged CPB [9]. These improvements are attributed to optimized myocardial protection strategies and refined minimally invasive techniques, which are particularly advantageous for elderly patients or those with limited cardiac reserve. Additionally, our data suggest comparable efficacy between beating-heart and cardioplegia arrest techniques in ameliorating pulmonary hypertension (P > 0.05). Maintaining continuous cardiac contraction preserves electrophysiological stability, potentially reducing postoperative arrhythmia risk [14]. Mechanistically, avoiding aortic cross-clamping decreases microemboli and systemic embolism risk while shortening the duration of nonphysiological circulation [15]—fundamental to the clinical value of robot-assisted beating-heart surgery. Notably, the beating-heart technique is associated with distinct technical challenges. A blood-filled surgical field may compromise visualization and operational precision, while the risk of air embolism is increased—particularly during the repair of large ASDs [16]. To mitigate these challenges, a systematic approach was implemented: (1) utilization of the Da Vinci surgical training system to expedite the learning curve; (2) recommendation of a slightly larger incision during the initial proficiency phase, with gradual reduction to balance operational feasibility and minimally invasive outcomes. For technical refinements, we adopted an innovative strategy to avoid inferior vena cava (IVC) occlusion. In large ASD patients, the IVC rim is often deficient; traditional IVC snaring can pucker the inferior edge of the defect, complicating suture lines and increasing residual shunt risk. By avoiding IVC occlusion, we enable precise defect closure. To mitigate the risk of air embolism, we position the IVC cannula tip at the orifice with negative pressure suction—a method used by many experts, who have reported that it does not compromise venous drainage or cause air embolism [6,17,18]. Preventing air embolism is critical in beating-heart surgery [6,12]. Meticulous techniques and procedural modifications can mitigate embolic and cerebrovascular risks. As proposed by Dang et al. [6], measures include maintaining high arterial pressure, ensuring that the left heart chambers remain blood-filled, flooding cavities with carbon dioxide, and brief lung inflation before ASD repair is completed. Using a chain-type occluding clamp optimizes the surgical space, and if venous pressure increases, temporary loosening of the superior vena cava snare or auxiliary suction ensures safe operation. Robot-assisted ASD repair is characterized by a learning curve for operative and CPB times, with both metrics decreasing as surgeon experience accumulates [19,20]. However, its operational complexity and high cost continue to hinder its widespread adoption [21]. Postoperative complications were observed: one beating-heart patient developed a coagulation disorder coinciding with postoperative menstrual onset [22], leading to thoracic hemorrhage necessitating rethoracotomy—likely exacerbated by suction-induced iatrogenic trauma. In the cardioplegic arrest group, one patient needed rethoracotomy for ascending aortic cannulation site bleeding, another had inadvertent coronary sinus closure requiring repeat CPB, and one beating-heart patient had a small residual shunt, likely due to intraoperative assessment difficulty in a blood-filled field [23]. Readmission was another concern: three beating-heart patients were readmitted for groin incision dehiscence (influenced by the closure technique, healing capacity, and postoperative care [24]), and one developed pericardial effusion treated with steroid therapy. A cardioplegia arrest patient was readmitted for femoral vein cannulation site thrombosis, which improved with anticoagulation. Femoral vein cannulation can damage the endothelium, and postoperative diuresis, hemoconcentration, and immobility create a prothrombotic state [25]. After a similar complication in a robot-assisted atrial tumor resection patient, we implemented oral rivaroxaban for 1 month, with no subsequent thrombotic events. Several limitations of this study should be considered when interpreting the findings. First, the single-center, retrospective design is susceptible to inherent selection bias. Furthermore, the inclusion of cases performed by a single surgeon over an 11-year period introduces potential confounding variables, including the evolution of the surgeon's technique (i.e., the learning curve) and technological advancements in surgical instrumentation. Second, the small sample size limits the generalizability of our conclusions and the statistical power of our analyses. Consequently, these findings should be regarded as preliminary and warrant validation in larger, prospective studies. Additionally, certain outcomes, such as the length of ICU stay, may have been influenced by nonclinical factors, including variations in individual patient recovery trajectories, hospital bed availability, and administrative scheduling around public holidays. Moreover, the absence of a comprehensive assessment of postoperative quality of life precludes a complete understanding of the long-term benefits of the procedure from the patient's perspective. Future research should prioritize multicenter, prospective, randomized controlled trials with larger cohorts. Such studies should incorporate long-term follow-up and validate quality-of-life assessments to provide a more definitive evaluation of the procedure's efficacy and its impact on patient satisfaction. Conclusion Robot-assisted beating-heart ASD repair is safe and feasible, offering significant advantages: avoidance of aortic cross-clamping-related myocardial ischemia‒ reperfusion injury, reduction in CPB duration, and acceleration of postoperative recovery (shorter mechanical ventilation, ICU, and hospital stays). Strict air embolism prevention strategies ensure safety, with no clinically identifiable events. Future studies will focus on large-sample long-term follow-up and quality-of-life assessments to further refine and promote this technology. Abbreviations ASD Atrial septal defect BMI Body mass index CPB Cardiopulmonary bypass ICU Intensive care unit LVEF Left ventricular ejection fraction NYHA New York Heart Association TEE Transesophageal echocardiography Declarations Acknowledgements None to declare. Authors’ Contributions Sumin Yang, Wei Wang, and Qingjiang Wang participated in the surgery. Haoyan Li, Xun Chi, and Ziang Sun participated in data collection. Qingjiang Wang and Rui Dai contributed to revising and drafting the manuscript. All authors read and approved the final manuscript. Funding No funding was received for this study. Data Availability The data of the current study are available from the corresponding author on request. Ethics Approval and Consent to Participate This study was approved by the institutional review board of The Affiliated Hospital of Qingdao University (Approval number QYFY WZLL 30733). Since the study was a retrospective study, informed consent was waived by the Ethics Committee. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Consent for Publication Not applicable. Competing Interests The authors declare no competing interests. References Brida M, Chessa M, Celermajer D, Li W, Geva T, Khairy P, et al. Atrial septal defect in adulthood: a new paradigm for congenital heart disease. Eur Heart J. 2022;43:2660–71. Roberson DA, Cui W, Patel D, Tsang W, Sugeng L, Weinert L, et al. Three-Dimensional Transesophageal Echocardiography of Atrial Septal Defect: A Qualitative and Quantitative Anatomic Study. J Am Soc Echocardiogr. 2011;24:600–10. Naqvi N, McCarthy KP, Ho SY. Anatomy of the atrial septum and interatrial communications. J Thorac Dis. 2018;10:S2837–47. Shrivastava S, Shrivastava S, Allu SVV, Schmidt P. Transcatheter Closure of Atrial Septal Defect: A Review of Currently Used Devices. Cureus [Internet]. 2023 [cited 2025 Jun 22]; Available from: https://www.cureus.com/articles/157438-transcatheter-closure-of-atrial-septal-defect-a-review-of-currently-used-devices Wu S-J, Fan Y-F, Chien C-Y. Surgical or interventional treatment for adult patients with atrial septal defect and atrial fibrillation: A systemic review and meta-analysis. Asian J Surg. 2022;45:62–7. Dang HQ, Le HT, Nguyen HS. Totally Endoscopic Surgery for Repairing Sinus Venosus Atrial Septal Defect Using Double-Patch Technique on Beating Heart. Innov Technol Tech Cardiothorac Vasc Surg. 2023;18:247–53. Fida Z, Ghutai G, Jamil Z, Dalvi AA, Hassaan M, Khalid K et al. The Role of Robotics in Cardiac Surgery: Innovations, Outcomes, and Future Prospects. Cureus [Internet]. 2024 [cited 2025 Jun 22]; Available from: https://www.cureus.com/articles/310858-the-role-of-robotics-in-cardiac-surgery-innovations-outcomes-and-future-prospects Kearney K, Lau EM, Darley D, Romfh A, Bart N, Kotlyar E, et al. Waitlist and post-transplant outcomes for eisenmenger syndrome: A comparison of transplant strategies. J Heart Lung Transpl. 2021;40:841–9. Boudoulas KD, Marmagkiolis K, Boudoulas H. Atrial Septal Defect Sizing and Transcatheter Closure. Cardiology. 2019;142:105–8. Konstantinov IE, Kotani Y, Buratto E, Schulz A, Ivanov Y. Minimally invasive approaches to atrial septal defect closure. JTCVS Tech. 2022;14:184–90. Tasoudis PT, Caranasos TG, Doulamis IP. Robotic applications for intracardiac and endovascular procedures. Trends Cardiovasc Med. 2024;34:110–7. Yun T, Kim H, Sohn B, Chang HW, Lim C, Park K-H. Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery. J Chest Surg. 2022;55:55–60. Senay S, Gullu AU, Kocyigit M, Degirmencioglu A, Karabulut H, Alhan C. Robotic atrial septal defect closure. Multimed Man Cardio-Thorac Surg. 2014;2014:mmu014–014. Berger T, Kreibich M, Rylski B, Morlock J, Kondov S, Scheumann J et al. Evaluation of myocardial injury, the need for vasopressors and inotropic support in beating-heart aortic arch surgery. J Cardiovasc Surg (Torino) [Internet]. 2020 [cited 2025 Jun 29];61. Available from: https://www.minervamedica.it/index2.php?show=R37Y 2020N04A0505. Fuchigami T, Nishioka M, Tamashiro Y, Nagata N. Beating heart thoracic aortic surgery under selective myocardial perfusion for patients with congenital aortic anomalies. Gen Thorac Cardiovasc Surg. 2020;68:956–61. Tang Y, Wu Y, Zhu J, Liu X, Zhou J, Huang H, et al. Total endoscopic repair of atrial septal defect under on-pump beating heart. J Thorac Dis. 2018;10:6557–62. Nakayama R, Takaya Y, Akagi T, Watanabe N, Ikeda M, Nakagawa K, et al. Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System. J Am Soc Echocardiogr. 2019;32:811–6. Nguyen UH, Dang HQ, Nguyen HC, Le TN. Intermediate-Term Outcomes of Totally Endoscopic Atrial Septal Defect Repair on Beating Heart in Small Children. Innov Technol Tech Cardiothorac Vasc Surg. 2022;17:223–30. Bonaros N, Schachner T, Oehlinger A, Ruetzler E, Kolbitsch C, Dichtl W, et al. Robotically Assisted Totally Endoscopic Atrial Septal Defect Repair: Insights From Operative Times, Learning Curves, and Clinical Outcome. Ann Thorac Surg. 2006;82:687–93. Gao C, Yang M, Wang G, Wang J. Totally robotic resection of myxoma and atrial septal defect repair. Interact Cardiovasc Thorac Surg. 2008;7:947–50. Tomšič A, Palmen M. Robotic mitral valve repair surgery: where do we go from here? Front Cardiovasc Med. 2023;10:1156495. Saracoglu A, Ezelsoy M, Saracoglu KT. Postoperative thrombotic effects of tranexamic acid in open heart surgery. Ir J Med Sci 1971 -. 2019;188:1373–8. Siondalski P, Jarmoszewicz K, Rogowski J, Jurowiecki J. Emergency surgical closure of postinfarction ventricular septal defect on the beating heart. Interact Cardiovasc Thorac Surg. 2006;6:160–2. Pozzi M, Henaine R, Grinberg D, Robin J, Saroul C, Desebbe O et al. Total percutaneous femoral vessels cannulation for minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2. Gulkarov I, Khusid E, Worku B, Demissie S, Guerges M, Salemi A, et al. Meta-Analysis of the Effect of Vascular Complications on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation. Ann Vasc Surg. 2021;71:488–95. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers agreed at journal 17 Nov, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviews received at journal 16 Nov, 2025 Reviewers agreed at journal 14 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Editor assigned by journal 11 Nov, 2025 Editor invited by journal 06 Nov, 2025 Submission checks completed at journal 06 Nov, 2025 First submitted to journal 06 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7961339","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":548982759,"identity":"c494534c-0725-41d0-90d9-c8864a4928cf","order_by":0,"name":"Qingjiang Wang","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Qingjiang","middleName":"","lastName":"Wang","suffix":""},{"id":548982760,"identity":"2ab21604-a1f3-4e0a-ad74-2bddc1e47dfc","order_by":1,"name":"Rui Dai","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Dai","suffix":""},{"id":548982761,"identity":"7be2e2ec-f365-4ef7-82e9-2e799f0802ac","order_by":2,"name":"Wei Wang","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wang","suffix":""},{"id":548982762,"identity":"71216794-d7c6-44dc-8de1-745cc52893d8","order_by":3,"name":"Haoyan Li","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Haoyan","middleName":"","lastName":"Li","suffix":""},{"id":548982764,"identity":"2acb27c6-964c-4a1d-b095-641f17da6ed2","order_by":4,"name":"Xun Chi","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Xun","middleName":"","lastName":"Chi","suffix":""},{"id":548982765,"identity":"b09b2ce9-0620-423d-a5bd-8bf47dc0f9cf","order_by":5,"name":"Ziang Sun","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Ziang","middleName":"","lastName":"Sun","suffix":""},{"id":548982766,"identity":"bb01d4e0-1dae-4a0f-93a7-6f41e2ca3b78","order_by":6,"name":"Sumin Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACNvbmgw8SKiTs+CGMGsJa+HiOJRs8OGOTLNkDZhwjrEVOIkdN8GFbGuOGGzlqkg9bmIlwGM8ZNoaEM4eZDW7ksFUkNrAx8Ld3JxDwS+8xoBcO80meeXvsRuIOGQaJM2c3ELDlXLoByBa+43lpNxKBVhpI5BLQIpFjJpHYdpix4UCOWUFiGzPRWtIYJ5zIMWMgTgsokBOggSyRcOYYD0G/yLc3H3z4AxqVH39U1Mjxt/fi14IBeEhTPgpGwSgYBaMAKwAAtFlR0i/0IJwAAAAASUVORK5CYII=","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":true,"prefix":"","firstName":"Sumin","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2025-10-27 14:50:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7961339/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7961339/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96709805,"identity":"4433be7e-f8f0-4024-92b4-9eb50871d78b","added_by":"auto","created_at":"2025-11-25 10:09:42","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4542313,"visible":true,"origin":"","legend":"","description":"","filename":"11.6DaVinciRobotassistedBeatingHeartvs.CardioplegicArrestAtrialSeptalDefectRepairAClinicalComparisonofFeasibilityandOutcomes.docx","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/5d86157e0f5ea9a6ed070777.docx"},{"id":96615846,"identity":"8774197f-6c9d-4acc-acd5-fe7af9122c5f","added_by":"auto","created_at":"2025-11-24 10:20:12","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8431,"visible":true,"origin":"","legend":"","description":"","filename":"862d9e65d14d4cd6b4e8acd7c86bb262.json","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/c311ae6d8c3eaac520bd96bb.json"},{"id":96708800,"identity":"9bea7e9d-c9e3-44e3-959b-1313b57378e9","added_by":"auto","created_at":"2025-11-25 10:05:29","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":93641,"visible":true,"origin":"","legend":"","description":"","filename":"862d9e65d14d4cd6b4e8acd7c86bb2621enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/6eb73651ea4121fa07d3227d.xml"},{"id":96615851,"identity":"389b5a09-33b5-4baa-a865-572fc30c597a","added_by":"auto","created_at":"2025-11-24 10:20:12","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":242963,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/d9519081c1c5abd626aebda6.png"},{"id":96615853,"identity":"07348265-ff8f-4fae-9d95-ed5a32c0d4fc","added_by":"auto","created_at":"2025-11-24 10:20:12","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":196331,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/ee7d84a806997fd925dcdad1.png"},{"id":96615854,"identity":"3fc7f3da-b039-452b-b96f-ac3a6f574bda","added_by":"auto","created_at":"2025-11-24 10:20:12","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91266,"visible":true,"origin":"","legend":"","description":"","filename":"862d9e65d14d4cd6b4e8acd7c86bb2621structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/152861bd2098e985706c04fc.xml"},{"id":96615849,"identity":"f922f86f-28c3-42bd-b139-a31417f71cd8","added_by":"auto","created_at":"2025-11-24 10:20:12","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":100081,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/9bbb691fc0f95277c5d85dc4.html"},{"id":96615848,"identity":"0da68b0a-4fce-470e-8a8c-84d308e7345a","added_by":"auto","created_at":"2025-11-24 10:20:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2410826,"visible":true,"origin":"","legend":"\u003cp\u003ePatient position. \u003cstrong\u003ea:\u003c/strong\u003e \u0026nbsp;double-lumen endotracheal intubation, \u003cstrong\u003eb:\u003c/strong\u003e superior vena cava drainage \u0026nbsp;\u0026nbsp;tube, \u003cstrong\u003ec:\u003c/strong\u003e central venous catheter, \u003cstrong\u003ed:\u003c/strong\u003e external defibrillation \u0026nbsp;\u0026nbsp;electrodes\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/2f781a03784f57a2278a87ca.png"},{"id":96708219,"identity":"98c92999-8a3c-4cb2-a1a5-1fa1bcad8d9f","added_by":"auto","created_at":"2025-11-25 09:59:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2066394,"visible":true,"origin":"","legend":"\u003cp\u003ePort sites. \u003cstrong\u003ea:\u003c/strong\u003e port site of robotic arm 1, \u003cstrong\u003eb:\u003c/strong\u003e port site of robotic arm 2, \u003cstrong\u003ec:\u003c/strong\u003e port site of the camera and for the assistant, \u003cstrong\u003ed:\u003c/strong\u003eport site of the retractor\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/4e18772725fc009d82dca857.png"},{"id":96712679,"identity":"71373213-48f6-449c-9abe-e36fe8a5a26a","added_by":"auto","created_at":"2025-11-25 10:16:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5115594,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7961339/v1/12f7e04e-39a9-4b06-905f-e6b1f1ed066f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Da Vinci Robot-assisted Beating-Heart vs. Cardioplegic Arrest Atrial Septal Defect Repair: A Clinical Comparison of Feasibility and Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAtrial septal defect (ASD) is the most prevalent congenital heart disease (CHD) in adults, accounting for 25\u0026ndash;30% of new diagnoses [1]. Secundum ASD is the most common anatomical subtype, followed by primary, sinus venosus, and coronary sinus defects [2,3]. Transcatheter closure is the preferred approach for eligible patients [4], whereas surgical repair remains the mainstay for defects with deficient rims, excessive size, multifenestration, failed catheter closure, or concomitant intracardiac anomalies [5].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e baseline characteristics of the patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4056%;\"\u003e\n \u003cp\u003eCardioplegic Arrest group (\u003cem\u003en\u003c/em\u003e=23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8042%;\"\u003e\n \u003cp\u003eBeating-Heart group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eAge\u0026nbsp;（years）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e43.87 \u0026plusmn; 16.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e38.28 \u0026plusmn; 16.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003emale gender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e11 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e53 (70.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e23.60 \u0026plusmn; 3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e23.46 \u0026plusmn; 4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.884\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eNYHA class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.686\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e29 (38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e33 (44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e13 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eComorbidities, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;First - degree Atrioventricular Block or Right Bundle - Branch Block\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e18 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.506\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;Atrial Fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e8 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;Coronary Heart Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.556\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e5 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e8 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;Diabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eCerebrovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.570\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eEchocardiographic data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003e\u0026nbsp;ASD size (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e2.73 \u0026plusmn; 0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e2.62 \u0026plusmn; 0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.593\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003eLVEF (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e62 (60\u0026ndash;64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e62 (60\u0026ndash;63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.2587%;\"\u003e\n \u003cp\u003ePulmonary artery pressure(mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.4056%;\"\u003e\n \u003cp\u003e45 (39\u0026ndash;65)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8042%;\"\u003e\n \u003cp\u003e45 (40\u0026ndash;52)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5315%;\"\u003e\n \u003cp\u003e0.798\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI:\u0026nbsp;\u003c/strong\u003eBody Mass Index,\u003cstrong\u003e\u0026nbsp;NYHA:\u0026nbsp;\u003c/strong\u003eNew York Heart Association,\u003cstrong\u003e\u0026nbsp;ASD:\u0026nbsp;\u003c/strong\u003eAtrial Septal Defect, \u003cstrong\u003eLVEF:\u0026nbsp;\u003c/strong\u003eLeft Ventricular Ejection Fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe Da Vinci robot-assisted ASD repair has been widely accepted as a safe and effective minimally invasive alternative [6]. However, technical complexities (e.g., intracorporeal knot tying) and steep learning curves have constrained its widespread adoption [7]. To address these issues, we optimized the surgical protocol to facilitate beating-heart ASD repair. Since November 2014, our institution has performed 560 Da Vinci robot-assisted procedures, including 98 ASD repairs. This retrospective study compared the outcomes of robot-assisted ASD repair with and without cardioplegia to validate the advantages of beating-heart surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u003c/strong\u003e This study was approved by the institutional review board of The Affiliated Hospital of Qingdao University (Approval number QYFY WZLL 30733). Since the study was a retrospective study, informed consent was waived by the Ethics Committee. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Selection and Grouping\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were preoperatively diagnosed with ASD via transthoracic echocardiography, which evaluated the defect type, size, left ventricular ejection fraction (LVEF), and pulmonary artery pressure. Patients aged \u0026ge;50 years underwent coronary angiography to exclude concomitant coronary artery disease. Exclusion criteria included the requirement for complex cardiac surgeries. The inclusion criteria were as follows: (1) body weight \u0026gt;40 kg; (2) no thoracic disease/surgery causing right thoracic adhesions; and (3) no aortic aneurysm or femoral arteriovenous malformation.\u003c/p\u003e\n\u003cp\u003eFrom November 2014 to April 2024, 98 patients underwent the Da Vinci robot-assisted ASD repair at our hospital. They were divided into Group 1 (23 cases, cardioplegia arrest repair with aortic cross-clamping) and Group 2 (75 cases, beating-heart repair). Preoperative characteristics (\u003cstrong\u003eTable 1\u003c/strong\u003e) were comparable between the groups in terms of age, sex, body mass index (BMI), New York Heart Association (NYHA) class, LVEF, and pulmonary artery pressure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent general anesthesia with double-lumen tracheal intubation and selective left lung ventilation. Transesophageal echocardiography (TEE) and arterial pressure monitoring were performed. A central venous catheter was inserted into the right internal jugular vein, together with a 16-Fr venous cannula for superior vena cava drainage. External defibrillator pads were positioned on the right shoulder-back and cardiac apex. Patients were placed in a supine position with the right chest elevated 15\u0026ndash;25\u0026deg; and the right arm adducted (\u003cstrong\u003eFig. 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eUnder selective left lung ventilation, a 1-cm incision was made at the fourth intercostal space midclavicular line for endoscopic exploration. If unremarkable, the incision was extended to 3\u0026ndash;5 cm as the main working/endoscope port.\u003c/p\u003e\n\u003cp\u003eFollowing systemic heparinization, cannulation via the femoral artery/vein initiates cardiopulmonary bypass (CPB). Five-millimeter incisions at the third, fifth, and sixth intercostal spaces were created for the robotic arms and the atrial retractor (\u003cstrong\u003eFig. 2\u003c/strong\u003e). The pericardium was incised \u0026ge;2 cm from the phrenic nerve, exposing the aorta and vena cava, with snares placed around the vena cava.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCardioplegia group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurse-string sutures were placed at the aortic root for cardioplegia catheter insertion. A chain clamp was used to occlude the ascending aorta, followed by cardioplegia infusion. After cardioplegia arrest, the vena cava was clamped, and the right atrium was incised via the robot. The ASD was exposed with retractors, and direct suture or patch repair was performed. Before suturing, the left lung was inflated to evacuate the air. The aortic clamp was released, and after the heart resumed beating, the right atrium was closed. The root catheter was removed after deairing, and purse-string sutures were tied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeating- Heart Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe vena cava was clamped, respiration was paused, and the right atrium was incised while the heart beat. An intracardiac suction device aspirates blood to expose the ASD, which is repaired by direct suture or a patch. Left lung inflation before suture tying ensured air evacuation. The right atrium was closed with a double-layer 4\u0026ndash;0 Prolene suture.\u003c/p\u003e\n\u003cp\u003eAfter unclamping the vena cava, TEE confirmed the integrity of the ASD closure. Following CPB weaning, the femoral venous cannula was removed. The superior vena cava cannula was heparin flush, clamped, and removed in the ICU. A chest drain was placed via the sixth intercostal incision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Shapiro‒Wilk test was used to verify the normal distribution of continuous variables, which are expressed as the mean \u0026plusmn; standard deviation and were compared via Student\u0026rsquo;s t- test. Nonnormally distributed variables are expressed as medians [interquartile ranges (IQRs)] and were compared with the Mann‒Whitney U test. Categorical variables are expressed as frequencies (%) and were compared with the chi-square test or Fisher\u0026rsquo;s exact test. Propensity score matching was unnecessary because of comparable baseline characteristics. Analyses were performed via SPSS 26.0, with P \u0026lt; 0.05 considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e Intraoperative data of the patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCardioplegic Arrest group (\u003cem\u003en\u003c/em\u003e=23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBeating-Heart group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e260 (230\u0026ndash;300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200 (180\u0026ndash;240)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCPB time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e149.87 \u0026plusmn; 50.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81.07 \u0026plusmn; 20.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAortic cross-clamp time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71.43 \u0026plusmn; 24.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 \u0026plusmn; 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eASD closure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Primary closure, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (91.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (74.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Patch closure, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRBC transfusion (U)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0\u0026ndash;1.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSternotomy conversion, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPB:\u0026nbsp;\u003c/strong\u003eCardiopulmonary Bypass, \u003cstrong\u003eASD:\u0026nbsp;\u003c/strong\u003eAtrial Septal Defect, \u003cstrong\u003eRBC:\u0026nbsp;\u003c/strong\u003eRed Blood Cell\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results","content":"\u003cp\u003eAll procedures were performed by the same surgeon, with successful ASD repair in both groups and no perioperative or 30-day mortality. No conversion to minoracotomy/sternotomy was needed, and no device-related complications occurred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e Postoperative data of the patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eCardioplegic Arrest group (\u003cem\u003en\u003c/em\u003e=23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eBeating-Heart group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003emechanical ventilation time (h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e15 (12\u0026ndash;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e11 (8\u0026ndash;14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePostoperative 24-hour drainage volume (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e230 (160\u0026ndash;330)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e120 (70\u0026ndash;200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eLength of ICU stay (h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e87 (63\u0026ndash;94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e66 (42\u0026ndash;80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003epostoperative hospital stay (d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e11 (9\u0026ndash;14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9 (8\u0026ndash;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eRBC transfusion (u)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.204\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eEarly mortality, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eComplications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eResidual atrial septal defect shunt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;Re-exploration for bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;New stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNew onset atrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e3 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePostoperative surgical site infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eVentricular premature beats\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePericardial effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eSecond cardiopulmonary bypass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePulmonary infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e3 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eLiver dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePneumothorax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eLower extremity vascular\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eHospital readmission, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e30 - day mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eEchocardiographic data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eLVEF (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e62 (61\u0026ndash;63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e61 (60\u0026ndash;63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.283\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePulmonary artery pressure(mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e28 (25\u0026ndash;34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e30 (25\u0026ndash;34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e1-month post-operative\u0026nbsp;Echocardiographic data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eLVEF (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e62 (60\u0026ndash;64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e62 (60\u0026ndash;63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePulmonary artery pressure(mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e24 (20\u0026ndash;32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e28 (23\u0026ndash;31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICU:\u0026nbsp;\u003c/strong\u003eIntensive Care Unit\u003cstrong\u003e, ASD:\u0026nbsp;\u003c/strong\u003eAtrial Septal Defect, \u003cstrong\u003eLVEF:\u0026nbsp;\u003c/strong\u003eLeft Ventricular Ejection Fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e Test statistics for changes in LVEF and pulmonary artery pressure \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLVEF - Postoperative LVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostoperative LVEF -\u0026nbsp;1-month post-operative\u0026nbsp;LVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePulmonary artery pressure - Postoperative pulmonary artery pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostoperative pulmonary artery pressure - 1-month post-operative pulmonary artery pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.763\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.209\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-8.151\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-2.122\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"530\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 530px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ea:\u003c/strong\u003e Wilcoxon Signed Ranks Test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 530px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eb:\u0026nbsp;\u003c/strong\u003eBased on negative ranks.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLVEF:\u0026nbsp;\u003c/strong\u003eLeft Ventricular Ejection Fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe beating-heart group presented significantly shorter operation times [200 (180\u0026ndash;240) min vs. 260 (230\u0026ndash;300) min, P \u0026lt; 0.001], CPB times (81.07 \u0026plusmn; 20.95 min vs. 149.87 \u0026plusmn; 50.50 min, P \u0026lt; 0.001), and aortic cross-clamp times (0 \u0026plusmn; 0 min vs. 71.43 \u0026plusmn; 24.45 min, P \u0026lt; 0.001) (\u003cstrong\u003eTable 2\u003c/strong\u003e). The ASD patch repair rate was 91.3% in the cardioplegia arrest group and 74.7% in the beating-heart group (P = 0.144), whereas red blood cell transfusion rates did not differ significantly (P = 0.056).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e Test statistics for group comparisons of LVEF and pulmonary artery pressure changes \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostoperative LVEF - LVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-month post-operative\u0026nbsp;LVEF -\u0026nbsp;Postoperative LVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostoperative pulmonary artery pressure - Pulmonary artery pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-month post-operative pulmonary artery pressure - Postoperative pulmonary artery pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.594\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.788\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ec\u003c/strong\u003e: Grouping Variable: Cardioplegic arrest group=0, Beating-heart group=1\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLVEF:\u0026nbsp;\u003c/strong\u003eLeft Ventricular Ejection Fraction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePulmonary artery pressure decreased significantly from baseline to postoperative (Z = \u0026minus;8.151, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and at 1 month (Z = \u0026minus;2.122, \u003cem\u003eP\u003c/em\u003e = 0.034), whereas LVEF changes were not significant (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05) (\u003cstrong\u003eTable 4\u003c/strong\u003e). The group comparisons revealed no significant interactions over time (P \u0026gt; 0.05), indicating similar trend trajectories (\u003cstrong\u003eTable 5\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAtrial septal defect (ASD) represents a common congenital cardiac anomaly that, if left untreated, may progress to severe complications such as pulmonary hypertension—particularly in patients with large or symptomatic defects [8]. While traditional open-heart surgery remains the gold standard for complex ASDs [9], the Da Vinci Surgical System has emerged as a viable minimally invasive alternative [10]. Its technical advantages—including three-dimensional stereoscopic visualization and robotic arms with seven degrees of freedom—afford substantial clinical benefits, such as reduced surgical trauma and accelerated postoperative recovery [11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo primary strategies dominate Da Vinci-assisted ASD repair. The conventional cardioplegic arrest technique, which relies on cardiopulmonary bypass (CPB) to create a static surgical field, has a well-documented safety profile [12,13]. In contrast, the emerging beating-heart technique maintains continuous cardiac contraction, thereby eliminating myocardial ischemia-reperfusion injury [12]. This approach offers distinct advantages: shorter CPB duration, reduced embolism risk, and preservation of electrophysiological stability. Clinically, the beating-heart technique has demonstrated superiority in myocardial protection, coagulation function preservation, and postoperative complication reduction, establishing it as an innovative modality for minimally invasive ASD repair [6].\u003c/p\u003e\n\u003cp\u003eOur findings demonstrated that the beating-heart group exhibited significantly greater surgical efficiency than did the cardioplegia arrest group. The median operative time was substantially shorter in the beating-heart cohort [200 (180–240) min vs. 260 (230–300) min, P \u0026lt; 0.001], accompanied by a 46% reduction in the mean CPB time (81.07 ± 20.95 min vs. 149.87 ± 50.50 min, P \u0026lt; 0.001) and complete elimination of aortic cross-clamping (0±0 min vs. 71.43 ± 24.45 min, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Postoperative recovery metrics were also markedly improved in the beating-heart group. Patients in this cohort had a 27% shorter median mechanical ventilation duration [11 (8–14) h vs. 15 (12–20) h, \u003cem\u003eP\u003c/em\u003e = 0.001], a 48% lower median 24-hour chest drainage volume [120 (70–200) mL vs. 230 (160–330) mL, \u003cem\u003eP\u003c/em\u003e \u0026lt;\u0026nbsp;0.001], and shorter stays in both the ICU stay [66 (42–80) h vs. 87 (63–94) h, \u003cem\u003eP\u003c/em\u003e = 0.018] and postoperative hospital stay [9 (8–11) d vs. 11 (9–14) d,\u003cem\u003e\u0026nbsp;P\u003c/em\u003e = 0.013], resulting in an 18% shorter overall hospitalization. In terms of adverse events, while the incidence rates of pulmonary infection (2.7% vs. 13.0%, P = 0.083) and ventricular premature beats (1.3% vs. 8.7%, P = 0.136) were significantly lower in the beating-heart group than in the control group, these differences did not reach statistical significance. Both groups showed significant improvement in postoperative pulmonary artery pressure (P \u0026lt; 0.001), with continued improvement at the 1-month follow-up (P = 0.034). The left ventricular ejection fraction (LVEF) remained stable in both groups, with no significant intergroup difference (P \u0026gt; 0.05). These findings highlight the benefits of avoiding aortic cross-clamping and shortening the duration of CPB, which effectively reduces the risks of a systemic inflammatory response and coagulation dysfunction associated with prolonged CPB\u0026nbsp;[9]. These improvements are attributed to optimized myocardial protection strategies and refined minimally invasive techniques, which are particularly advantageous for elderly patients or those with limited cardiac reserve. Additionally, our data suggest comparable efficacy between beating-heart and cardioplegia arrest techniques in ameliorating pulmonary hypertension (P \u0026gt; 0.05). Maintaining continuous cardiac contraction preserves electrophysiological stability, potentially reducing postoperative arrhythmia risk\u0026nbsp;[14]. Mechanistically, avoiding aortic cross-clamping decreases microemboli and systemic embolism risk while shortening the duration of nonphysiological circulation\u0026nbsp;[15]—fundamental to the clinical value of robot-assisted beating-heart surgery.\u003c/p\u003e\n\u003cp\u003eNotably, the beating-heart technique is associated with distinct technical challenges. A blood-filled surgical field may compromise visualization and operational precision, while the risk of air embolism is increased—particularly during the repair of large ASDs [16]. To mitigate these challenges, a systematic approach was implemented: (1) utilization of the Da Vinci surgical training system to expedite the learning curve; (2) recommendation of a slightly larger incision during the initial proficiency phase, with gradual reduction to balance operational feasibility and minimally invasive outcomes. For technical refinements, we adopted an innovative strategy to avoid inferior vena cava (IVC) occlusion. In large ASD patients, the IVC rim is often deficient; traditional IVC snaring can pucker the inferior edge of the defect, complicating suture lines and increasing residual shunt risk. By avoiding IVC occlusion, we enable precise defect closure. To mitigate the risk of air embolism, we position the IVC cannula tip at the orifice with negative pressure suction—a method used by many experts, who have reported that it does not compromise venous drainage or cause air embolism [6,17,18]. Preventing air embolism is critical in beating-heart surgery [6,12]. Meticulous techniques and procedural modifications can mitigate embolic and cerebrovascular risks. As proposed by Dang et al. [6], measures include maintaining high arterial pressure, ensuring that the left heart chambers remain blood-filled, flooding cavities with carbon dioxide, and brief lung inflation before ASD repair is completed. Using a chain-type occluding clamp optimizes the surgical space, and if venous pressure increases, temporary loosening of the superior vena cava snare or auxiliary suction ensures safe operation.\u003c/p\u003e\n\u003cp\u003eRobot-assisted ASD repair is characterized by a learning curve for operative and CPB times, with both metrics decreasing as surgeon experience accumulates\u0026nbsp;[19,20]. However, its operational complexity and high cost continue to hinder its widespread adoption\u0026nbsp;[21]. Postoperative complications were observed: one beating-heart patient developed a coagulation disorder coinciding with postoperative menstrual onset [22], leading to thoracic hemorrhage necessitating rethoracotomy—likely exacerbated by suction-induced iatrogenic trauma. In the cardioplegic arrest group, one patient needed rethoracotomy for ascending aortic cannulation site bleeding, another had inadvertent coronary sinus closure requiring repeat CPB, and one beating-heart patient had a small residual shunt, likely due to intraoperative assessment difficulty in a blood-filled field [23]. Readmission was another concern: three beating-heart patients were readmitted for groin incision dehiscence (influenced by the closure technique, healing capacity, and postoperative care [24]), and one developed pericardial effusion treated with steroid therapy. A cardioplegia arrest patient was readmitted for femoral vein cannulation site thrombosis, which improved with anticoagulation. Femoral vein cannulation can damage the endothelium, and postoperative diuresis, hemoconcentration, and immobility create a prothrombotic state [25]. After a similar complication in a robot-assisted atrial tumor resection patient, we implemented oral rivaroxaban for 1 month, with no subsequent thrombotic events.\u003c/p\u003e\n\u003cp\u003eSeveral limitations of this study should be considered when interpreting the findings. First, the single-center, retrospective design is susceptible to inherent selection bias. Furthermore, the inclusion of cases performed by a single surgeon over an 11-year period introduces potential confounding variables, including the evolution of the surgeon's technique (i.e., the learning curve) and technological advancements in surgical instrumentation. Second, the small sample size limits the generalizability of our conclusions and the statistical power of our analyses. Consequently, these findings should be regarded as preliminary and warrant validation in larger, prospective studies. Additionally, certain outcomes, such as the length of ICU stay, may have been influenced by nonclinical factors, including variations in individual patient recovery trajectories, hospital bed availability, and administrative scheduling around public holidays. Moreover, the absence of a comprehensive assessment of postoperative quality of life precludes a complete understanding of the long-term benefits of the procedure from the patient's perspective. Future research should prioritize multicenter, prospective, randomized controlled trials with larger cohorts. Such studies should incorporate long-term follow-up and validate quality-of-life assessments to provide a more definitive evaluation of the procedure's efficacy and its impact on patient satisfaction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRobot-assisted beating-heart ASD repair is safe and feasible, offering significant advantages: avoidance of aortic cross-clamping-related myocardial ischemia‒ reperfusion injury, reduction in CPB duration, and acceleration of postoperative recovery (shorter mechanical ventilation, ICU, and hospital stays). Strict air embolism prevention strategies ensure safety, with no clinically identifiable events. Future studies will focus on large-sample long-term follow-up and quality-of-life assessments to further refine and promote this technology.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eASD\u0026nbsp;\u003c/strong\u003eAtrial septal defect\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI\u0026nbsp;\u003c/strong\u003eBody mass index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCPB\u0026nbsp;\u003c/strong\u003eCardiopulmonary bypass\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICU\u0026nbsp;\u003c/strong\u003eIntensive care unit\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLVEF\u0026nbsp;\u003c/strong\u003eLeft ventricular ejection fraction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNYHA\u0026nbsp;\u003c/strong\u003eNew York Heart Association\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTEE\u0026nbsp;\u003c/strong\u003eTransesophageal echocardiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSumin Yang, Wei Wang, and Qingjiang Wang participated in the surgery. Haoyan Li, Xun Chi, and Ziang Sun participated in data collection. Qingjiang Wang and Rui Dai contributed to revising and drafting the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of the current study are available from the corresponding author on request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board of The Affiliated Hospital of Qingdao University (Approval number QYFY WZLL 30733). Since the study was a retrospective study, informed consent was waived by the Ethics Committee. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBrida M, Chessa M, Celermajer D, Li W, Geva T, Khairy P, et al. Atrial septal defect in adulthood: a new paradigm for congenital heart disease. Eur Heart J. 2022;43:2660\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoberson DA, Cui W, Patel D, Tsang W, Sugeng L, Weinert L, et al. Three-Dimensional Transesophageal Echocardiography of Atrial Septal Defect: A Qualitative and Quantitative Anatomic Study. J Am Soc Echocardiogr. 2011;24:600\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNaqvi N, McCarthy KP, Ho SY. Anatomy of the atrial septum and interatrial communications. J Thorac Dis. 2018;10:S2837\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShrivastava S, Shrivastava S, Allu SVV, Schmidt P. Transcatheter Closure of Atrial Septal Defect: A Review of Currently Used Devices. Cureus [Internet]. 2023 [cited 2025 Jun 22]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cureus.com/articles/157438-transcatheter-closure-of-atrial-septal-defect-a-review-of-currently-used-devices\u003c/span\u003e\u003cspan address=\"https://www.cureus.com/articles/157438-transcatheter-closure-of-atrial-septal-defect-a-review-of-currently-used-devices\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu S-J, Fan Y-F, Chien C-Y. Surgical or interventional treatment for adult patients with atrial septal defect and atrial fibrillation: A systemic review and meta-analysis. Asian J Surg. 2022;45:62\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDang HQ, Le HT, Nguyen HS. Totally Endoscopic Surgery for Repairing Sinus Venosus Atrial Septal Defect Using Double-Patch Technique on Beating Heart. Innov Technol Tech Cardiothorac Vasc Surg. 2023;18:247\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFida Z, Ghutai G, Jamil Z, Dalvi AA, Hassaan M, Khalid K et al. The Role of Robotics in Cardiac Surgery: Innovations, Outcomes, and Future Prospects. Cureus [Internet]. 2024 [cited 2025 Jun 22]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cureus.com/articles/310858-the-role-of-robotics-in-cardiac-surgery-innovations-outcomes-and-future-prospects\u003c/span\u003e\u003cspan address=\"https://www.cureus.com/articles/310858-the-role-of-robotics-in-cardiac-surgery-innovations-outcomes-and-future-prospects\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKearney K, Lau EM, Darley D, Romfh A, Bart N, Kotlyar E, et al. Waitlist and post-transplant outcomes for eisenmenger syndrome: A comparison of transplant strategies. J Heart Lung Transpl. 2021;40:841\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoudoulas KD, Marmagkiolis K, Boudoulas H. Atrial Septal Defect Sizing and Transcatheter Closure. Cardiology. 2019;142:105\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKonstantinov IE, Kotani Y, Buratto E, Schulz A, Ivanov Y. Minimally invasive approaches to atrial septal defect closure. JTCVS Tech. 2022;14:184\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTasoudis PT, Caranasos TG, Doulamis IP. Robotic applications for intracardiac and endovascular procedures. Trends Cardiovasc Med. 2024;34:110\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYun T, Kim H, Sohn B, Chang HW, Lim C, Park K-H. Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery. J Chest Surg. 2022;55:55\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSenay S, Gullu AU, Kocyigit M, Degirmencioglu A, Karabulut H, Alhan C. Robotic atrial septal defect closure. Multimed Man Cardio-Thorac Surg. 2014;2014:mmu014\u0026ndash;014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerger T, Kreibich M, Rylski B, Morlock J, Kondov S, Scheumann J et al. Evaluation of myocardial injury, the need for vasopressors and inotropic support in beating-heart aortic arch surgery. J Cardiovasc Surg (Torino) [Internet]. 2020 [cited 2025 Jun 29];61. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.minervamedica.it/index2.php?show=R37Y\u003c/span\u003e\u003cspan address=\"https://www.minervamedica.it/index2.php?show=R37Y\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e2020N04A0505.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFuchigami T, Nishioka M, Tamashiro Y, Nagata N. Beating heart thoracic aortic surgery under selective myocardial perfusion for patients with congenital aortic anomalies. Gen Thorac Cardiovasc Surg. 2020;68:956\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTang Y, Wu Y, Zhu J, Liu X, Zhou J, Huang H, et al. Total endoscopic repair of atrial septal defect under on-pump beating heart. J Thorac Dis. 2018;10:6557\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakayama R, Takaya Y, Akagi T, Watanabe N, Ikeda M, Nakagawa K, et al. Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System. J Am Soc Echocardiogr. 2019;32:811\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNguyen UH, Dang HQ, Nguyen HC, Le TN. Intermediate-Term Outcomes of Totally Endoscopic Atrial Septal Defect Repair on Beating Heart in Small Children. Innov Technol Tech Cardiothorac Vasc Surg. 2022;17:223\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonaros N, Schachner T, Oehlinger A, Ruetzler E, Kolbitsch C, Dichtl W, et al. Robotically Assisted Totally Endoscopic Atrial Septal Defect Repair: Insights From Operative Times, Learning Curves, and Clinical Outcome. Ann Thorac Surg. 2006;82:687\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGao C, Yang M, Wang G, Wang J. Totally robotic resection of myxoma and atrial septal defect repair. Interact Cardiovasc Thorac Surg. 2008;7:947\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTomšič A, Palmen M. Robotic mitral valve repair surgery: where do we go from here? Front Cardiovasc Med. 2023;10:1156495.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaracoglu A, Ezelsoy M, Saracoglu KT. Postoperative thrombotic effects of tranexamic acid in open heart surgery. Ir J Med Sci 1971 -. 2019;188:1373\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiondalski P, Jarmoszewicz K, Rogowski J, Jurowiecki J. Emergency surgical closure of postinfarction ventricular septal defect on the beating heart. Interact Cardiovasc Thorac Surg. 2006;6:160\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePozzi M, Henaine R, Grinberg D, Robin J, Saroul C, Desebbe O et al. Total percutaneous femoral vessels cannulation for minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGulkarov I, Khusid E, Worku B, Demissie S, Guerges M, Salemi A, et al. Meta-Analysis of the Effect of Vascular Complications on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation. Ann Vasc Surg. 2021;71:488\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7961339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7961339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDa Vinci robot-assisted cardiac surgery has emerged as an indispensable modality in minimally invasive cardiac surgery. This study aimed to compare the clinical outcomes of Da Vinci robot-assisted atrial septal defect (ASD) repair under beating-heart versus cardioplegic arrest conditions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective cohort study was conducted on consecutive patients who underwent Da Vinci robot-assisted ASD repair at our institution from November 2014 to April 2024. Patients were stratified into two groups on the basis of the surgical approach: the cardioplegia arrest group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23) and the beating-heart group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;75). General clinical data, perioperative parameters, postoperative recovery metrics, and early clinical outcomes were compared between the groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 114 patients underwent successful Da Vinci robot-assisted ASD repair, with no perioperative or 30-day mortality. Compared with the cardioplegic arrest group (n\u0026thinsp;=\u0026thinsp;23), the beating-heart group (n\u0026thinsp;=\u0026thinsp;75) presented a significantly shorter cardiopulmonary bypass (CPB) time (81.07\u0026thinsp;\u0026plusmn;\u0026thinsp;20.95 min vs. 149.87\u0026thinsp;\u0026plusmn;\u0026thinsp;50.50 min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and eliminated aortic cross-clamping (0\u0026thinsp;\u0026plusmn;\u0026thinsp;0 min vs. 71.43\u0026thinsp;\u0026plusmn;\u0026thinsp;24.45 min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The operative time was significantly shorter in the beating-heart group [200 (180\u0026ndash;240) min vs. 260 (230\u0026ndash;300) min, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Postoperatively, the beating-heart group required less mechanical ventilation [11 (8\u0026ndash;14) h vs. 15 (12\u0026ndash;20) h, P\u0026thinsp;=\u0026thinsp;0.001], had a lower 24-hour drainage volume [120 (70\u0026ndash;200) mL vs. 230 (160\u0026ndash;330) mL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001], and had a shorter intensive care unit (ICU) stay [66 (42\u0026ndash;80) h vs. 87 (63\u0026ndash;94) h, P\u0026thinsp;=\u0026thinsp;0.018]. Complication rates were comparable between the groups, with no residual shunts or severe arrhythmias.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eDa Vinci robot-assisted beating-heart ASD repair is safe and feasible, avoids aortic cross-clamping-related risks, significantly reduces the CPB time, and offers postoperative recovery advantages.\u003c/p\u003e","manuscriptTitle":"Da Vinci Robot-assisted Beating-Heart vs. Cardioplegic Arrest Atrial Septal Defect Repair: A Clinical Comparison of Feasibility and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 10:20:07","doi":"10.21203/rs.3.rs-7961339/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"239294736561931246302114297982232689651","date":"2026-01-11T21:35:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64611306191953925679200524454255136764","date":"2026-01-04T00:45:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283651936140331022936972103594004331517","date":"2025-11-17T13:00:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151096302805887817919087036330301249793","date":"2025-11-17T05:59:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T15:48:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282812440802746032761338141947043209293","date":"2025-11-14T11:24:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-12T02:10:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-11T12:28:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-06T14:20:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-06T14:04:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-11-06T14:01:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f818d75d-0bb3-4a43-837e-0de19f635b8d","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T10:20:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 10:20:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7961339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7961339","identity":"rs-7961339","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}