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We report the case of a 60-year-old man requiring combined mitral valve repair and coronary artery bypass grafting. A unique minimally invasive approach was used combining robotic internal mammary artery harvesting, partial lower sternotomy, and single vessel coronary artery bypass grafting using an automated distal coronary artery anastomotic device. Issues in approaching the commonly encountered patient with mitral valve disease and coronary artery disease using minimally invasive techniques are discussed.

To the Editor, The Laerdal SimManÒ 3G mannequin (Laerdal USA, Wappingers Falls, NY, USA) is widely used for highfidelity simulation. Nevertheless, providers familiar with mechanical ventilators commonly notice a lower lung compliance, necessitating lower set tidal volumes (V T) to reduce airway pressure. SimMan 3G is 180 cm tall, which corresponds to an ideal body weight of 75 kg (according to http://www.ardsnet.org/tools.shtml) and a V T of 600 mL at 8 mLÁkg-1. This ''normal'' V T without positive endexpiratory pressure (PEEP) results in a peak airway pressure of 34 cmH 2 O. For a V T of 500 mL, the peak airway pressure was 28 cmH 2 O and the static airway compliance was 24 mLÁcmH 2 O-1. This static airway compliance of the stock mannequin is about 30-50% of typical human values. 1 These values are reproducible among six SimMan 3G mannequins to which our group has access. Adding PEEP exacerbates problems with highpressure alarms, and a PEEP above 5 cmH 2 O and V T of 500 mL results in an air leak greater than 2 LÁmin-2 (ventilator bellows cannot be driven with 2 LÁmin-1 flow). The high peak airway pressures and air leak are frequently noticed in simulation sessions for maintenance of certification in anesthesia done for the American Board of Anesthesiology. High airway pressures may mislead participants by suggesting acute lung injury, endotracheal tube kinking, or a mucus plug. This causes trainee