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Ann Thorac Surg 2003;76:1126-1130
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Expanded use of suction and stabilization devices in cardiothoracic surgery

^a The National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London, England, United Kingdom
^b Department of Cardiothoracic Surgery, St. Mary's Hospital London, London, England, United Kingdom

Accepted for publication April 8, 2003.

^* Address reprint requests to Dr Athanasiou, 70 St. Olaf's Rd, Fulham, London SW6 7DN, England, United Kingdom.
e-mail: tathan5253{at}aol.com

	Abstract

Top Abstract Introduction Material and methods Results Comment Conclusion References

 
BACKGROUND: Recent developments in beating heart instrumentation have allowed surgeons to perform multivessel off-pump coronary artery bypass surgery by overcoming the factors that impair surgical performance (limited visualization, continuous movement of the target area, and hemodynamic instability during exposure of the inferior and posterior parts of the heart). We have explored the possibility of further expanding apical and epicardial suction devices beyond their ordinary use in coronary artery surgery.

METHODS: A retrospective review of our cardiac surgery database was undertaken to identify the incidences in which these devices have been used in a somewhat novel manner in the field of cardiac surgery.

RESULTS: During this time period we identified 20 instances in which either apical or epicardial suction devices were used alone or together. The nature of the procedures included dividing pericardial adhesions (pericardiectomy, n = 2; dividing adhesions in redo-coronary surgery, n = 4), securing epicardial hemostases (penetrating cardiac trauma, n = 2; securing hemostasis during reexploration after cardiac surgery, n = 10), and facilitating epicardial microwave ablation (n = 2). On all 20 occasions the intended procedures were undertaken uneventfully. Furthermore, the use of apical and epicardial devices greatly facilitated the operative procedures and avoided the use of cardiopulmonary bypass on all occasions.

CONCLUSIONS: In summary, we would like to highlight the expanding role for apical and epicardial suction devices to an area beyond coronary artery surgery in which we have found their use invaluable.

	Introduction

Top Abstract Introduction Material and methods Results Comment Conclusion References

 
Increasing interest and experience in off-pump coronary artery bypass (OPCAB) surgery has led to the development of specialized devices allowing exposure and stabilization of all the surgical territories of the heart. These devices include epicardial suction tissue stabilizers, which provide a near motionless region of the epicardium, and apical suction devices, which allow displacement and lifting of the heart while minimizing hemodynamic instability by preventing the distortion of the right ventricle [1] and mitral valve annulus [2].

Recently, we have found both types of suction devices to be useful beyond their conventional role. In this article we review our experience of using suction devices in expanded roles, such as division and dissection of intrapericardial adhesions, securing epicardial hemostasis without the use of cardiopulmonary bypass (CPB), and epicardial microwave ablation for chronic atrial fibrillation.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Conclusion References

 
We retrospectively reviewed our cardiac surgery database from 1999 to 2002, and identified all occasions in which suction devices were used in a somewhat novel manner, referred to as an expanded role in the field of cardiac surgery. We were not only interested in the procedures undertaken, but also the potential advantages associated with the application of these devices.

	Results

Top Abstract Introduction Material and methods Results Comment Conclusion References

 
During the established time period, we identified 20 instances in which either the apical (n = 16) (Starfish I [Medronic Inc, Minneapolis, MN] or Guidant Xpose [Guidant Corp, Cupertino, CA]) or epicardial suction devices (n = 14) (Octopus III [Medronic Inc, Minneapolis, MN] or Guidant Axius^TM [Guidant Corp, Cupertino, CA]) were used either alone or together in an expanded role. These instances included division of intrapericardial adhesions (n = 6), securing epicardial hemostasis without the use of cardiopulmonary bypass (n = 12), and epicardial microwave ablation for atrial fibrillation in combination with OPCAB surgery (n = 2).

Division of intrapericardial adhesions: pericardiectomy and redo-coronary surgery
We identified 6 patients who had suction devices that greatly facilitated the division of pericardial adhesions particularly on the lateral and posterior aspects of the heart. This avoided CPB in 2 patients with constrictive pericarditis undergoing complete pericardiectomy (including the resection of posterior pericardium) and 4 patients undergoing redo coronary artery bypass grafting (CABG) in which complete mobilization of the heart was achieved.

In all 6 patients intrapericardial structures were mobilized gradually. Right-sided structures and the aorta were mobilized first; thereafter the heart was dissected free from the intrapericardial adhesions. Once the anterior and inferior heart surfaces were dissected free, the apical suction device was employed. Gradual retraction of the stabilizing arm toward the surgeon's side allowed the lateral and posterior aspects of the heart to be visualized and allowed further adhesions to be divided (Fig 1). The epicardial stabilizing device was also employed while dissecting the lateral and inferior aspect of the heart, which enabled progressive retraction and displacement toward the surgeon, minimizing the quantity of instrumentation required in the operating field. In dissecting the posterior pericardial adhesions, both apical and epicardial suction devices were used together to allow cephalad retraction of the heart, exposing the posterior pericardium. The degree of negative suction used was adjusted for each patient, taking into account the friability of the epicardial tissues so that myocardial injury (ie, tears, hematomas, bleeding) could be avoided.

View larger version (84K): [in this window] [in a new window]   Fig 1. Use of apical suction devices during pericardiectomy.

View larger version (59K): [in this window] [in a new window]   Fig 2. (A) Expanded use of apical suction and epicardial stabilization devices. (B) Repair of penetrating injury of the left ventricle. Repair of bleeding from the left internal mammary artery to the obtuse marginal artery (OM) anastomosis.

Epicardial microwave ablation for chronic atrial fibrillation in combination with OPCAB surgery
In the 2 patients who underwent epicardial microwave ablation procedures, the apical suction device was used to facilitate exposure of the posterolateral and inferior aspects of the heart. This allowed the surgeon full access to the pulmonary veins, inferior cava, and left atrium to isolate them electrically. As a result, the beating heart was adequately stabilized when the lesion was created, avoiding damage to the adjacent circumflex artery. This exposure also facilitated both the application of a stapler or ligation and division of the left atrial appendage.

	Comment

Top Abstract Introduction Material and methods Results Comment Conclusion References

 
Apical and epicardial suction devices are now routinely used to perform complete surgical revascularization without cardiopulmonary bypass. The design of these devices has rapidly changed in recent times. Presently these devices provide a near motionless operative field while maintaining hemodynamic function by preventing right ventricular and mitral apparatus distortion [1, 2]. We have increasingly explored the possibility of using both devices either alone or together to perform procedures on the beating heart, whereas this previously also required the need for cardiopulmonary bypass.

The division of pericardial adhesions is an essential part of all redo cardiac surgical procedures, allowing the heart and aorta to be mobilized. Counter-traction is often necessary during the procedure, and if it is provided by hand, it carries the risk of further hemodynamically compromising a heart that is already restricted by adhesions, thus increasing the risk of arrhythmia. The lateral and posterior aspects of the heart are most sensitive to such a disturbance and are often left until cardiopulmonary bypass is established. We have found the suction devices particularly valuable in gaining access to this part of the heart, allowing excellent visualization of the operating field, free of manual retraction. Furthermore, gentle and gradual counter-traction can be applied to the heart, giving a good hemodynamic profile even during difficult dissections. An important point to note in this situation is the difference between the two apical suction cup devices. Whereas the Starfish I (Medronic Inc, Minneapolis, MN) has a three-part suction head, the Guidant Xpose (Guidant Corp, Cupertino, CA) has a conical cup. The practical significance of this difference in shape in terms of hemodynamic disturbances has not yet been evaluated.

The role of pericardiectomy in constrictive pericarditis is well established and the operative goal is to dissect away the pericardium from the epicardial surface. The greatest benefits are realized with complete pericardiectomy (including the posterior and lateral pericardium), and the role of CPB for this has been previously emphasized [3]. The suction devices mentioned in this article have been particularly useful in dissecting the posterior and lateral pericardium from the epicardial surface.

Epicardial bleeding can result from penetrating injury to the heart (ie, lacerations to coronary arteries or direct penetrating injury to the heart), bleeding from coronary artery anastomosis after CABG surgery, or from injury to the epicardial vessels during division of pericardial adhesions. The surgical approach to a lacerating lesion of the coronary artery depends on the location of the laceration. Proximal coronary artery injuries are usually treated by direct revascularization using CPB. However, if the coronary laceration is distal and CPB is to be avoided (such as in a multiply injured patient), the artery can be ligated with the potential risk of myocardial infarction. A lower perioperative mortality has been demonstrated in emergency myocardial revascularization with OPCAB surgery when compared with conventional CABG, supporting the belief that OPCAB surgery is both safe and effective in a hemodynamically compromised situation [4]. We and others have previously reported the use of this approach to treat lacerations of the LAD [5, 6]. Repair of penetrating cardiac injuries affecting coronary vessels or the surface of the heart can be facilitated by apical or epicardial suction devices, or by both devices. In the past, other devices such as clamps and Foley catheters have been used [7, 8], however more complex penetrating injuries affecting the valves and septum require the use of cardiopulmonary bypass [9].

The incidence of reexploration to secure hemostasis depends on numerous factors, including clinical variables specific to the patient and whether or not the initial procedure was undertaken with or without cardiopulmonary bypass. The incidence of reexploration for hemorrhage after CABG has been reported to be between 3% and 15%, often resulting in hemodynamic compromise [10]. We have found the use of these stabilization devices invaluable in visualization of distal anastamoses, especially on the lateral and inferior surfaces of the heart. This has enabled us to secure hemostasis with precision and without the need to institute CPB before manipulating the heart. We believe that these devices can also be used to facilitate revision of grafts and allow repair or redo of the entire distal anastomosis if required. This approach has been particularly valuable when repairing complex bleeding points, such as the heel of the left internal mammary artery to the LAD anastamosis (Table 1).

It has recently been reported that electrical isolation of the pulmonary veins can be performed with microwave ablation, especially without cardiopulmonary bypass [11]. Although our examples support this report, the role of suction devices to facilitate this procedure has not yet been clarified.

	Conclusion

Top Abstract Introduction Material and methods Results Comment Conclusion References

 
In conclusion, suction stabilizing devices, both apical and epicardial, were originally designed solely for the purpose of coronary artery revascularization. However, they are a useful adjunct to cardiac procedures, reducing the need for cardiopulmonary bypass. Furthermore, their use can improve surgical performance and precision in emergency operations where optimal visualization and reduction of target movement is critical [12]. In all the applications described in this report, the use of these devices has the added advantage of not only being safe and relatively noninvasive, but these devices also allow the surgical assistant to be free to help with other aspects of the procedure. This may even allow future, independent operations in emergency situations.

	References

Top Abstract Introduction Material and methods Results Comment Conclusion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pankaj Kumar Sharif Al-Ruzzeh Alexandros Charitou Brian Glenville Roberto Casula Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Athanasiou, T. Articles by Casula, R. Search for Related Content PubMed PubMed Citation Articles by Athanasiou, T. Articles by Casula, R. Related Collections Cardiac - other