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310 P. Starinieri
Fig. 3 Air removal device to “actively” evacuate entrained air
Fig. 4 Safety features in a MiECC circuit
MiECC as Support for Endoscopic Cardiac Surgery 311
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VENTING
Fig. 5 Venting possibilities using a MiECC circuit
valves prevent excessive suction and accidental
introduction of air into the heart. These should be
used on all vents running through a roller
pump. In some cases it is possible to place a vent
in the pulmonary artery (PA) to remove blood
going to the lungs and back to the left atrium.
Vent return can be initiated for aortic root and
pulmonary artery by the use of negative pressure
in the venous line. A closed optimized perfusion
circuit or MiECC Type II or III can be used when
a PA vent is placed (Fig. 5). This closed circuit,
MiECC type II or III, is secured by a bubble
sensor attached in the vent line before entering
the venous line and which is linked to the arterial
clamp. When a bubble is detected, the sensor will
automatically trigger the arterial clamp, which
will close and gives the opportunity to put a
tubing clamp below the vent bubble trap. Continuation of the circulation and the possibility to
de-air the vent bubble trap through a roller pump
towards the cell-salvage device (Fig. 6), is a
major advantage.
4.6 Cardioplegia
One of the major concerns of cardiac surgery is
protection of the heart during the operation.
Whether intracellular solutions with a low
sodium degree but a high degree of potassium are
used or extracellular solutions with concentrations of sodium higher or equal to 70 mmol/L
together with concentrations of potassium from 5
to 3 mmol/L, a well-protected heart that recovers
from the arrest period serves as the objective.
The repair of the heart is of no use if the heart has
not been adequately protected. The surgeon
desires a bloodless, motionless heart on which to
perform his delicate anastomosis.
The search for this optimal cardioplegic
solution, with a quick arrest, prolonged electromechanical silence, minimal damage of
ischemia and controlled reperfusion, has resulted
in many variations of the solutions. It seems that
every institution has a particular prescription that
is followed. This solution of preference by each
312 P. Starinieri
Fig. 6 Properly de-airing the vent bubble trap with continuation of bypass
center is usually accomplished by a single line
(cristalloïd) or an arrangement of dual lines
(cristalloïd solution mixed with blood) that run
through a roller pump together or through two
separate roller pumps.
Using MiECC nowadays, variations of the
Calafiore method, whereby warm blood is taken
from the oxygenator and intermittently injected
into the aortic root, with concentrated potassium
added by means of a syringe pump, have
tremendous popularity.
In MICS procedures, the technique of cardioplegia delivery should ideally be based on a
system with minimal surface area and low dilutional volume. A mixture of blood, nourishing
the heart muscle, and cristalloïd solution which is
administrated with elegant simplicity, minimal
added volume and giving a plausible period of
time is an ideal method for a MICS approach.
(Table 2).
5 MiECC-Experience
The JESSA system Type III was used in a series
of 3000 consecutive patients, of whom 540
patients received procedures other than multivessel coronary bypass surgery by endoscopic set
up (AVR, SCAR and Bentall operations through
mini-sternotomy and previous mentioned procedures in combination with endosco pic coronary
bypass surgery).
All patients could be operated on using the
minimized closed circuit. Only one patient
required flooding of the surgical field due to air
entrainment in the venous line by a PFO (patent
foramen ovale) created during cannulation. In
this minimal invasive surgical approach, it is
difficult to close this small iatrogenic PFO. No
conversion to open CPB by adding a separate
venous reservoir was necessary.
MiECC as Support for Endoscopic Cardiac Surgery 313
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The JESSA modular hybrid system (Type IV)
was used in a series of 450 consecutive patients
receiving totally endoscopic aortic valve
replacement with the use of a pulmonary vein
vent or totally endoscopic mitral valve repair
whether or not with neo-chordal repair. Five
patients with a PFO required a conversion to an
open hybrid system (drainage of venous blood
will go directly to the venous reservoir instead of
going through the venous bubble trap) during
closure of the existing PFO. After c losing this
interatrial communication, the switch was again
made to a closed hybrid system (venous blood
going through the venous bubble trap instead of
going through the reservoir). All five patients
received mitral valve surgery.
We observed, with continuation of dual antiplatelet therapy, a need for intra-operative
transfusion of 0.45 ± 1.05 units, intraoperative
blood loss was 281.45 ± 112.13 mL and 24 h
bloodloss was 382.44 ± 169.15 mL. Overall
mortality was 1.78%. Based on the feasibility
and safety aspects of our system, MiECC
provides good clin ical results without compromising operative morbidity or mortality.
6 Conclusion
Advances in perfusion technology have been
widely implemented in the design of modern
cardiopulmonary bypass circuits and systems.
Circuits nowadays are getting smaller and systems more advanced [1–3]. When performing
MiECC, one is also forced using a certain strategy (separate suction of shed blood, retrograde
autologous priming). The circuit itself will not
contribute alone to the patients improved outcome but the MiECC strategy will facilitate the
surgeon in his minimal invasive approach as well
as creating the possibility for the anaesthesiologist to perform ultra-fast track anaesthetic technique. Using the MiECC strategy together with
this advanced perfusion technology provides a
safe environment for the team to work in (Videos
16 and 17).
Video 16 Flush circuit to cellsaver to retrieve all red bloodcells (1) (▶ https://doi.org/10.1007/000-a8h)
314 P. Starinieri
Video 17 Compilation of all chapters (▶ https://doi.org/10.1007/000-a91)
Appendixes
See Figs. 1, 2, 3, 4, 5, 6, Tables 1 and 2.
Table 1 List of videos perfusion
Video 1: CH01 – Start RAP
Video 4: CH04 – Position
Table
Video 2: CH02 – Start AAP Video 3: CH03 – Start
Video 5: CH05 – Excessive
Negative Pressure
CPB
Video 6: CH06 – Start
Air Purge Control
MiECC as Support for Endoscopic Cardiac Surgery 315
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Video 7: CH07 – Bolus
injection medication
Video 10: CH10 – Weaning
from bypass patient in
Trendelenburg
Video 8: CH08 – Bloodgas
sample
Video 11: CH11 – Reduce
RPM
Video 9: CH09 – Venous
bag empty - add volume
Video 12: CH12 – Flush
venous line
Video 13: CH13– Flush
antegrade the circuit
Video 14: CH14–
Retrieve blood from
venous cannula to
cellsaver
Video 15: CH15–
CH15– Retrieve
blood from arterial
line to cellsaver
316 P. Starinieri
Video 16: CH16– Flush
circuit to cellsaver to
Video 17: Compilation of
all chapters
retrieve all red bloodcells
(1)
Table 2 Mixed blood cardioplegia used during MICS procedures
Blood:Crystalloid cardioplegia (3:1)
Sodium 40 mmol/L
Magnesium 76 mmol/L
Chloride 262 mmol/L
Potassium 62 mmol/L
Calcium 1 mmol/L
Procaine 5 mmol/L
Aqua ad 500 mL
References
1. Pramod Reddy Kandakure, FRCS, Mark Batra, DNB,
Sandeep Garre, DM, Sai Nagendra Banovath, MD,
Farooq Shaikh, MBBS, and Krishna Pani, BSc. Direct
cannulation in minimally invasive cardiac surgery
with limited resources. Ann Thorac Surg.
2020;109:512–6.
2. De Somer F. Venous drainage—gravity or assisted?
Perfusion. 2011;26(S1):15–9.
3. Anastasiadis K, Antonitsis P, Argiriadou H,
Deliopoulos A, Grosomanidis V, Tossios P. Modular
minimally invasive extracorporeal circulation systems;
can they become the standard practice for performing
cardiac surgery? Perfusion. 2015;30(3):195–200.
Innovation in Cardiac Surgery: It
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Takes a Village—Our Team’s Story:
A Quest for Routine Sternal-Sparing
CABG
Jude S. Sauer
Abstract
Innovation is required to further enhance
cardiac surgery’s benefits for patients by
reducing the undesirable factors associated
with currently highly invasive procedures.
Patients deserve and will demand that routine
operations are deliberately designed to minimise postoperative pain, recovery time, complications, and life-altering medications.
While tiny bone-sparing minimally invasive
or, preferably, microinvasive access sites
through soft tissue between the ribs or in the
subxiphoid space can offer much less traumatic access to the heart, such small incisions
block direct visualisation and obviate
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_22. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
J. S. Sauer (&)
Division of Cardiac Surgery, Department of Surgery,
University of Rochester, Rochester, NY, USA
e-mail: jsauer@lsisolutions.com
LSI SOLUTIONS®, Victor, NY, USA
LSI EUROPE™,Düsseldorf, Germany
traditional tissue manipulation. Innovation
toward reliable and affordable customised
miniature surgical technology along with
facilitative real-time video-assisted endoscopic and augmented imaging can supplant
large, injurious surgical access sites to deliver
a more gentle, patient-centered paradigm. To
provide an example of a cardiac surgery
innovation effort, this chapter presents an
ongoing coronary revascularisation enhancement project. This R&D effort was undertaken
to provide new options toward reliable and
ergonomic sternal-sparing microinvasive
coronary artery bypass with efficient bilateral
internal thoracic artery harvest via subxiphoid
access and excellent anastomoses using
microthoracotomies. Recent initial clinical
results are encouraging. While many dedicated people consider it their privilege to
support the innovation of the enabling technology and techniques that will be essential to
build this next era, the attitudes and efforts of
indomitable heart surgeons regarding this
requisite innovation will be the driving force
to provide a brighter future for their patients.
The fate of heart surgery is in the hands of
today’s heart surgeons.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_22
317
318 J. S. Sauer
Keywords
Innovation in cardiac surgeryMinimally
invasive surgery
harvest
ITA
coronary revascularisation
Subxiphoid ITA harvestBilateral
Coronary revascularisationAll-arterial
Internal thoracic artery
1 Introduction
Good Designs are everywhere;
Great Designs are very rare
Innovation is required to further enhance cardiac
surgery’s benefits for patients by reducing the
undesirable factors associated with currently
highly invasive procedures. To remain an
acceptable option for today’s sophisticated
patients, heart surgery must undergo a positive
disruption to continue to deliver the best longterm functional results (e.g., optimised prosthetic
valves, durable revascularisation, etc.) while also
becoming more gentle to the patient (e.g.,
reduced pain along with a lower risk of protracted recoveries, stroke, death, etc.). Heart
surgery must also provide increased value to
society.
Patients deserve and will demand that routine
operations are deliberately designed to minimise
postoperative pain, recovery time, complications,
and life-altering medications. The acceptability
of procedure access wounds will be judged not
compared to the size of a sternotomy, but relative
to the invasiveness of endovascular access. Most
sternotomies and large thoracotomies must go
the way of using a patient’s parent for crosscirculation. The next era of heart surgery must
transcend the antiquated focus on 30 day mortality rates. Surgic al procedures should be
expected to be truly minimally invasive, with
mortality rates under 1%.
The current dependency on providing the
“standard of care” in heart surgery, if interpreted
too rigidly, is anti-innovation; this concept, which
is mostly of legal, not medical, construct, has a
commonly accepted definition: what a reasonable
surgeon would do under the same or similar circumstances. Less than 75 years ago, a reasonable
surgeon would simply let a patient with heart
disease die unmutilated by futile surgery. Standards must evolve. As is now witnessed in more
than 25 years of success across all other surgical
specialties, much less invasiveness in cardiac
surgery will become the only acceptable option.
While tiny bone-sparing microinvasive access
sites between the ribs or through the subxiphoid
space can offer significantly less traumatic access
to the heart, such small incisions block direct
visualisation and render traditional tissue
manipulation obsolete. Innovation toward reliable and affordable customised miniature surgical technology along with facilitative real-time
video endoscopic and augmented imaging can
supplant large injurious surgical access sites to
deliver a more gentle, patient-centered paradigm.
Productive partnerships between surgeons, surgical societies, academia, industry, and inventors
are critical to support progress. Additionally,
expediting the availability of safe and effective
clinical translation systems and convenient
training platforms will be crucial.
To provide an example of a cardiac surgery
innovation effort, this chapter presents highlights
from an ongoing coronary revascularisation
enhancement project targeting surgical access
only through soft tissue. Since 2016, this team
has pursued delivery of a microinvasive coronary
artery bypass (µCAB) procedure to realise reliable subxiphoid bilateral internal thoracic artery
(ITA) harvest and microthoracotomy (µT) anastomoses. Images from early laboratories in this
effort—including a prototype sternal retractor
setup, a subxiphoid approach to harvest, and an
endoscopic image—are shown in Fig. 1, from
this team’s January 2021 publication “A Novel
Subxiphoid Approach for Bilateral Internal
Thoracic Artery Harvesting.”
With today’s cardiopulmonary bypass outcomes demonstrating much lower risk, and the
not infrequent occurrence of off-pump CABG,
the two main goals of the µCAB subxiphoid and
µT revascularisation approach are:
Innovation in Cardiac Surgery: It Takes a Village Our Team’s Story: … 319
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Fig. 1 Images of Dr. Hossein Amirjamshidi conducting a cadaver lab, showing novel sternal retraction system and
subxiphoid access to ITA harvest
• Maintain the integrity of the chest wall.
• Retain excellent patency rates for ITA coro-
nary revascularisation grafts.
actual implementation. Meaningful innovation in
modern cardiac surgery must transform procedures to achieve both improved patient outcomes
and enhanced value.
Nothing that is hard is easy.
Great Surgery =
Great Outcomes + Great Recovery
2 Rallying to Innovation: Gentle
Heart Surgery
Truth passes through three stages:
First, it is ridiculed.
Second, it is violently opposed.
Third, it is accepted as being self-evident.
Arthur Schopenhauer (1788–1860)
Innovation =
The Implementation of Something New
Creativity requires nothing more than thinking
about novel concepts. Invention merely requires
a new design for a device or process without
To continue its long history of providing optimised benefits to patients, heart surgery must be
decoupled from painful, disabling, and protracted
postoperative recoveries that have a significant
risk of complications and death. Great heart
surgery is effective and gentle.
Value = Benefits/Cost
The value of cardiac surgery is measured by the
benefits provided over the true total costs to the
patient, the patient’s family, and society. Today’s
heart surgeons will be the key determining factor
of heart surgery’s value across the world during
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