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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
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330 J. S. Sauer
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Video 1 Subxiphoid bilateral mammary artery harvest (▶ https://doi.org/10.1007/000-a93)
can be technically daunting, especially without
the full access afforded by a traditional sternotomy, this ITA pedestal offers promise to make
anastomotic suturing substantially less difficult.
Because we appreciate that suturing a durable
and accurate coronary anastomosis with 7-0 or 80 suture (even with fully open access) remains
one of the most impressive skills in all of modern
surgery, we recognised that custom accessories
are needed to aid in this remote suturing.
The ped estal gently holds the distal ITA
inverted near the arteriotomy; it also incorporates
other features for suture management and guiding
the needles during suturing. Figure 9 is a close-up
of the pedestal in position adjacent to the target
site with anastomotic suture in place in an ex vivo
porcine model. The tissue pedestal is connected to
a table-mounted arm that allows its well controlled and stable positioning immediately adjacent to the target site within the µT access site.
For an end-to-side (e.g., LITA–LAD) anastomoses, the distal end of the ITA cobra head is
rotated *180 degrees within the pedestal to
enable anastomotic suturing. Recent research
regarding use of the pedestal for sequential arterial grafting appears promising (see Fig. 10). The
µCAB procedure is intended to enable sternalsparing all-arterial grafting beyond the single or
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Fig. 7 Progression of soft tissue retraction devices developed for µCAB
Fig. 8 Tissue pedestal design iterations
double bypass grafts from BITA end-to-side
anastomoses alone. Consideration of the use of
sequential anastomoses (e.g., skip grafts) and/or
additional arterial free grafts (e.g., radial artery or
RITA segment Y-graft) expands the potential to
surgically treat multivessel disease (Fig. 11).
µCAB: µT Access Anastomosis : Miniature
Titanium Fastener
Just as sewing with tiny suture is extremely difficult, manually tying tiny knots through a small,
remote access incision can be challenging and
unreliable for any surgeon. Based on COR-
332 J. S. Sauer
Fig. 9 Tissue pedestal holding graft vessel adjacent to target site
KNOT®technology, a smaller device was
developed for the placement of a miniaturised
titanium fastener to secure 6-0, 7-0, or 8-0
monofilament polypropylene suture and automatically trim both suture tails (Video 2).
Over the first five years of this project, the
end-to-side anastomosis in a porcine carcass
model (note: this anastomosis is the completion
of the vessels being sutured in Fig. 9); and two
titanium fasteners used to secure two sequential
ITA–coronary artery bypass anastomoses in an
ex vivo porcine model (Video 2).
miniature titanium fastener technology was put
through extensive research, development, and
testing in cadaver laboratories and in pig
carcasses and in vivo experiments. Figure 10,
from left to right, shows the distal tip of the
device as applied in a cadaver laboratory to
secure a LITA–LAD anastomosis; a miniature
United States, the COR-KNOT MICRO™ tita-
nium fasteners were first used in CABG patients
in July 2021 by Dr. Niv Ad; this technology has
subsequently been successfully used by 8 other
surgeons in 12 patients receiving coronary
revascularisation surgery (Video 3).
titanium fastener as placed to secure and
automatically trim the tails of 8-0 suture on an
flows in unexpected ways, especially over the
After receiving FDA 510(k) clearance in the
Innovation is a lengthy process that often
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Fig. 10 The miniature titanium fastener deployment device as used in a cadaver laboratory, once on an ITA graft in an
ex vivo porcine model, and twice on a sequential graft in an ex vivo porcine model
Fig. 11 Dr. Niv Ad using the COR-KNOT MICRO™Device for the first time in a patient (left); and a miniature
titanium fastener (in circle) securing 7-0 polypropylene suture used in a saphenous vein graft anastomosis
334 J. S. Sauer
Video 2 Enabling devices for Micro CABG (▶ https://doi.org/10.1007/000-a92)
Video 3 CorKnot Micro: First in Human case (▶ https://doi.org/10.1007/000-a94)
course of a long proje ct. Table 1 breaks down the
company’s µCAB revascularisation initiative by
both calendar year and project year, conservatively estimating the amoun t of time and
resources committed to advancing these innova-
tive technologies and techniques. Since 2016, the
µCAB initiative has consumed hundreds of
thousands of person hours, produced thousands
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Calendar year 2016 2017 2018 2019 2020 2021 Total
Project year PY1 PY2 PY3 PY4 PY5
Employee hours 4,080 34,116 34,745 134,136 162,953 370,030
Invention drawings 340 164 40 463 162 1,169
Engineering drawings 7 133 98 86 206 1,365
Pages written 2 1,136 955 1,021 3,660 6,774
Documents completed 1 278 140 169 440 1,028
Components produced 1,344 4,659 4,467 7,902 14,708 33,080
Table 1 Project µCAB: first five years
Devices built 24 264 341 649 785 2,063
336 J. S. Sauer
of pages of documents, required more than
30,000 components plus 2,000 devices, and cost
more than $30 million. This focus and energy has
been dedicated to enhance heart surgery toward a
more gentle patient-centered paradigm.
5 In Conclusion
Innovative thinking is a requirement for the
modern cardiac surgeon. This chapter is intended
to be a rallying cry to surgeons regarding the
need to innovate for the benefit of patients, surgeons, and society at large. Though significant
strides have been made toward optimising clinical outcomes since the early days of cardiac
surgery, many long-recognised opportunities for
innovation have gone unfulfilled. While novel
technology and techniques will be essential to
advancing cardiac surgery, the attitudes and
efforts of cardiac surgeons toward innovation
will be the driving force to providing a brighter
future for their patients.
There are many opportunities for innovation in
developing less invasive ways to operate on the
heart. Sternotomies and large thoracotomies must
go by the wayside in favor of tiny, microinvasive
access sites for the benefit of patients. While
nontraditional, less invasive approaches are often
thought of as cumbersome and difficult to accept,
enabling technology and facilitating imaging can
help optimise the widespread adoption of innovations worthy of pursuit by heart surgeons for
their patients. Heart surgery must be less traumatic, less risky, more efficient, and less complicated. Collectively, we must strive for a more
gentle, patient-centered paradigm.
The demands on the available time of practicing cardiac surgeons are significant. Innovation is often frustrating and draining. The reality
of the innovative process is that it is more costly
in terms of time, energy, and emotional capital
than one might expect . Simple solutions to
complex problems are essential, though they are
typically the most difficult to develop. We
humbly request that heart surgeons remain optimistic, keep a keen eye toward the horizon, and
maintain an open mind regarding opportunities
for meaningful innovation. New approaches can
and will benefit your patients and our world.
Partnership among clinical faculty and experienced industry partners can facilitate this process
for the mutual benefit of all involved.
Innovation or obsolescence? It is a great time
to be a great heart surgeon. Less invasive heart
surgery remains substantially behind relative to
the progress of other specialties. The availability
of innovative technologies that are customised
for remote surgery along with excellent endoscopic imaging can usher in a new golden era of
heart surgery. Significant positive disruption can
yield enormous positive impact. However, the
refinement and utilisation of promising techniques requires heart surgeons to command the
destiny of their noble field. Without the insight,
enthusiasm, and energy of heart surgeons, this
golden opportunity will ultimately fade. Patients
have demonstrated their willingness to accept
treatments that are potentially inferior in the long
term to avoid near-term pain and suffering.
Twenty-five years after a loud plea to advance
coronary revascularisation surgery by emphasising
less invasive techniques, it still remains unclear
whether most heart surgeons will embrace, or even
explore, this paradigm.
Great Surgery = Great Outcomes + Great
Recovery.
The future of heart surgery is in the hands of
today’s heart surgeons.
References
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4. Karagoz HY, Kurtoglu M, Ozerdem G, Battaloglu B,
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Additional Resources
9. Castillo Sang M, Answini G, Griffin J. Minimally
invasive mitral valve repair after endocarditis with
bileaflet prolapse using a modification of Leipzig
loop technique. CTSNet. 2019. https://doi.org/10.
25373/ctsnet.7808774.v1.
10. Fortunato G, Stoger G, Domenech AL, et al.
Balloon-expandable transcatheter mitral valve
replacement through minimally invasive approach
in big MAC. CTSNet. 2020. https://doi.org/10.
25373/ctsnet.13242311.v1.
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using automatic (Cor-Knot) device. CTSNet. 2021.
https://doi.org/10.25373/ctsnet.13957454.v1.
12. Pitsis A, Nikoloudakis N. Totally endoscopic aortic
valve replacement and transaortic mitral valve repair.
CTSNet. 2020. https://doi.org/10.25373/ctsnet.
11689443.v1.
13. Pitsis A, Nikoloudakis N, Kelpis T,
Economopoulos V. Totally endoscopic aortic valve
replacement using an automated annular suturing
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ctsnet.12024627.v1.
14. Pitsis A, Nikoloudakis N, Kelpis T,
Economopoulos V. Totally endoscopic aortic valve
replacement with a Trifecta GT bovine pericardial
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Economopoulos V. Totally endoscopic mitral valve
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Kelpis T. Totally endoscopic redo tricuspid valve
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2020. https://doi.org/10.25373/ctsnet.11502975.v1.
Psychological Context, Individual
Differences and Adjustment
in Relation to Cardiac Surgery Scars
Kate L. Green
Abstract
Cardiac surgery patients around the world
typically undergo a sternotomy approach.
Advances in cardiac surgery techniques presents patients with potentially increased
choice. Factors that impact on adjustment
and recovery post cardiac surgery are increasingly generating interest in relation to
post-operative outcomes. These include psychological context, individual differences and
adjustment in relation to cardiac surgery scars.
For a proportion of patients subjective perception of appearance difference (i.e. scars) post
cardiac surgery will be an important consideration. The psychological impact of the introduction of non-sternotomy approaches to heart
surgery is an emerging field of research that
could help to inform clinical decision making
and identify groups of patients who are likely
to benefit from a minimally invasive cardiac
surgery approach.
Keywords
Psychological contextCardiac surgery
Endoscopic cardiac surgery scars
K. L. Green (&)
Blackpool Teaching Hospitals NHS Foundation
Trust, Blackpool, UK
e-mail: drkategreen@gmail.com
Working as a Clinical Psychologist within a
Cardiac Centre, it has been a privilege to learn
about the individual experiences of cardiac
patients including those awaiting planned cardiac
surgery procedures and emergency admissions
which allo ws minimum time, if any, for the
patient to prepare for an invasive surgical procedure. The role involves psychological assessment, formulation and intervention at each stage
of the patient’s cardiac journey. Throughout
clinical work in this field, the relevance of historical factors, individual differences (examples
include personal characteristics, coping skills,
trauma history, social context, pre/post-operative
care and support) have been highlighted as
important factors in the process of pre and post
adjustment from initially receiving a cardiac
diagnosis and treatment sequelae including cardiac surgery.
As health professionals, we are in the unique
position of both accessing and delivering health
care. The range of presentations I have encountered working in cardiac services and breadth of
responses from patients prompted me to consider
my own experience of adjustment after surgery.
During adolescence, I was admitted for an urgent
appendectomy. Unfortunately the appendix ruptured into the peritoneum and following an
emergency procedure, my primary concern at the
time was the size/position of the surgical scar and
whether the drain site would ever heal. Postoperatively and as time elapsed, healing took place
and I was able to process what happened. Pre-
© 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_23
339
340 K. L. Green
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occupation with the scar diminished and I was
more inclined to think ‘I survived.’ This cognitive shift was part of the adjustment process and
it is likely the initial concern about the scar was
related to my age and stage of development, the
lack of prior experience of surgery and possibly a
focus away from the unexpected reminder of
mortality having only just commenced an
undergraduate degree. On reflection, several
protective factors including family support and
opportunities to vocalise my concerns with
individuals who were psychologically aware,
assisted my adjustment and enhanced my coping
skills to what had been a potentially lifethreatening event. More recently, working with
patients either preparing for or recovering from
cardiac surgery, I have continued to develop a
greater understanding about individual differences in factors that influence rehabilitation and
recovery.
I have since becom e awar e that it is not
uncommon for people to express increased concern about scars on their torso compared to parts
of their body that are typically exposed. There is
limited understanding about the possible reasons
for this but it is plausible to think that scars near
areas of the body usually concealed and or
associated with an individual’s sexual identity
could generate increased anxiety and issues
relating to body image. Scars on the torso, particularly for women, have been found to have an
association with poor adjustment [1]. The
strength of relationship between self-rated
severity of appearance and associated distress
has been documented in relation to skin scarring
and evidence suggests no correlations between
objective measures (e.g. scar size) and emotional
distress [2]. Clinically this has been observed
when one patient perceives their sternotomy scar
as a positive indicator of ‘survival’ and something to share almost like a ‘badge of honour.’ In
contrast, another patient feels repulsed by their
sternotomy scar and surrounding keloids which
negatively affects intimacy with his/her partner,
mood, self-confidence and quality of life.
Research suggests resilience is an important
factor in a person’s ability to cope with changes
to their appearance and outcome of treatment.
Variance in adjustment to changes in appearance,
the potential influence of physiological, developmental, social and cognitive factors and the
relevance of subjective severity of appearan ce
difference following cardiac surgery indicates a
need for consideration of these in service provision. Meaningful predictors of adjustment could
include prior experience of hospitalisation, illness beliefs, length of hospital stay, post cardiac
surgery infection, surgical approach and
pre/post-operative quality of care.
Focusing on surgical approach, the development of minimally invasive and endoscopic cardiac surgery techniques (non-sternotomy
approaches) presents the possibility of a smaller
scar compared to the traditional sternotomy. The
option of minimally invasive surgery is routinely
considered standard of care in other specialities
(examples include general surgery, orthopaedics
and lung cancer resection). Current literature, in
addition to clinical experience, indicates that
subjective perception of visible or non-visible
difference in appearance post cardiac surgery
could have psychological effects that impact on
adjustment. The literature also suggests variance
in the prevalence of Post Traumatic Stress
Disorder (PTSD) of 15–25% in postoperative
cardiac patients [3]. Symptoms of PTSD include
flashbacks, nightmares, psychological distress
and disturbed sleep all of which can significantly
impair function, adjustment and quality of life.
A younger age group of cardiac patient appears
to also be a vulnerability factor for developing
PTSD [4]. This highlights the importance of
identifying risk factors through comprehensive
assessment that incorporates historical information and possible higher risk of post-surgical
trauma. Subjective perception of the scar and
where clinically appropriate, selection of surgical
approach that seeks to optimise recovery both
from a physical and psychological perspective is
also indi cated. It is likely that the reported
prevalence of PTSD is among patients who have
undergone a sternotomy approach to their cardiac
problems. There is emerging evidence that a nonsternotomy, minimal access approach has statistically significant advantages in relation to body
image, self-esteem and aesthetic outcomes [5].
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