KR20020007347A - Apparatus and methods for cardiac surgery - Google Patents

Abstract

The present invention provides a stabilization device having legs that stabilize the patient's heart. This stabilization device has a first leg larger than the second leg. The first leg has sides that are used to contract other parts of the heart, and the contact surface stabilizes the target artery.

Description

Apparatus and methods for cardiac surgery

In conventional cardiac surgery, an incision is made at the chest between the ribs (thoracotomy) to access through the sternum (median sternum incision) or into the chest cavity. The retractor is placed in the thoracic incision to allow the sternum and tissue to open wide. Then, a surgical instrument is placed through the opening for the procedure in the heart.

One of the most common forms of cardiac surgery is coronary artery bypass grafting (CABG). In coronary replacement grafts, blockages in one or more coronary arteries are bypassed by connecting the graft to the coronary artery downstream of the blockage. The technique of connecting the graft to the coronary artery is known as conjugation. The graft may be a carotid artery dissected from the thoracic wall, the upstream end of the artery being left intact and its downstream end connected to the coronary artery. Optionally, the graft can be part of an artery or vein in another part of the patient's body, or can be made of an artificial vascular graft, the upstream end of the graft being connected to an artery such as the aorta and the downstream end of the graft Connected to the coronary arteries. In this manner, multiple coronary artery blockages present at various locations on the front, side, or back of the heart can be replaced using multiple grafts.

Conventionally, coronary replacement grafts have been performed with the heart at rest, with the patient relying on cardiopulmonary replacement, whereby the patient's fluids have been circulated by extracorporeal pumps and oxygenation systems. In some cases, however, coronary replacement graft is a technique known as "beating heart" or "off-pump" coronary artery bypass (OPCAB) instead of cardiopulmonary replacement. This can be done with a beating heart. In coronary artery replacement, the surface of the heart near the junction of the coronary artery is stabilized using certain tools while the heart is still beating. This local stabilization keeps the junction as motionless as possible with the graft connected to the coronary artery. The coronary artery is temporarily blocked or a temporary anastomosis is inserted into the coronary artery while conjugation maintains the site while flowing blood.

Basic functions required for coronary replacement procedures include sternum or rib traction, heart manipulation, heart stabilization, pericardial traction, coronary traction and hemostasis. Sternal traction involves lifting the opposite half of the divided sternum apart to open the thorax cavity. Cardiac manipulation involves moving, rotating, or lifting the heart to access coronary arteries on the front, back, or side of the heart. Cardiac stabilization is the process of stabilizing the surface of the pulsating heart near the junction so that the procedure is performed. Pericardial traction is used to pull the incision in the incision to facilitate access to the heart. Coronary artery traction includes placing a suture below the coronary artery near the junction and applying traction to the suture to expose the coronary artery. This traction can function to block the coronary arteries above and below the junction to provide hemostasis. In some cases, a temporary anastomosis may be inserted through an arterial incision in the coronary artery so that blood flows through the junction during the procedure.

This application is a partial continuation of US patent application Ser. No. 09 / 293,630, filed April 16, 1999, the content of which is incorporated herein by reference, and claims priority.

The present invention generally relates to surgical surgical tools, in particular retractors and tools for performing cardiac surgery.

1 is a perspective view of a traction and stabilization system according to the present invention.

FIG. 2 is a partial perspective view of the rear of the retractor in the system of FIG. 1; FIG.

3 is an assembly view of a fixed arm and a movable arm in the system of FIG.

4A and 4B are top and bottom perspective views of the suture stay in the system of FIG.

5 is a perspective view of a stabilization device and a mounting base mounted to the arm in the system of FIG. 1;

6-8 are front, side and plan views of the stabilizing device and mounting base of FIG. 5.

9 is a side cross-sectional view through the mounting base of FIG. 5.

10 is a front sectional view through the mounting base of FIG.

11 is a perspective view of the system of FIG. 1 in an incision position in the chest of a patient.

12a shows a perspective view of a further embodiment of a stabilization device according to the invention.

12B is a perspective assembled view of the remote portion of the stabilization device of FIG. 12A.

13 is a perspective view of a stabilization device and a blower according to the present invention.

14A-14C are perspective, top and side views of a cardiac retractor in accordance with the present invention.

15A and 15B are perspective and side views of a vascular clamp holder according to the present invention.

16 shows another stabilization device according to the invention.

17 is an illustration of an actuator biased into place by a pair of springs.

18 illustrates the operation of the actuator against the force of the spring to unlock the flexible arm.

19 is an exploded view of the flexible arm showing the link and friction enhancement layer.

20A is a cross sectional view of the near end of the arm showing the base link locked to the body;

20B shows a base link.

21 is a cross sectional view of the base link showing the base link freely pivoting relative to the body;

Fig. 22 is a sectional view showing a base link having a body moved to separate the serrated body.

23 shows a stabilization device partially removed from the rail on the retractor.

24 shows the stabilization device completely removed from the retractor.

25 is an illustration of the leg portion attached to the centrifugal end of the arm.

26 is a cross-sectional view of the centrifugal end of the arm.

27A is a plan view of the leg portion;

FIG. 27B is a side view of the leg portion of FIG. 27A; FIG.

28A is a side view of another leg portion;

28B is a plan view of the leg portion of FIG. 28A.

29 shows a stabilization device for holding a suction leg.

30 is an illustration of the clip for holding the suction lumen leading to the suction leg.

31 is a plan view of the suction leg;

32 is an illustration of the suction leg with the extension portion displaced;

33 is an illustration of the suction leg with the arms spaced apart.

34 is a bottom view of the suction leg;

35 shows another suction leg;

36 is a view of another leg portion;

FIG. 37 is a view of the leg portion of FIG. 36; FIG.

FIG. 38 is an end view of the leg portion of FIG. 36; FIG.

39 is a plan view of the leg portion of FIG. 36;

40 is an isometric view of the leg portion of FIG. 36.

41 is an end view of another leg;

42 is a plan view of the leg portion of FIG. 41;

43 is an isometric view of the leg portion of FIG. 41;

The present invention provides a system for performing coronary artery replacement and other forms of cardiac surgery that overcomes the deficiencies of many current devices. The system provides additional degrees of freedom and range of use over commercially available devices. The present invention enables sternum or rib traction, pericardial traction, cardiac manipulation, coronary artery traction and cardiac stabilization using a single integrated system. In providing the above functionality, the system of the present invention utilizes a reusable tow platform as a whole, thereby reducing the waste and costs associated with some current systems.

In a first embodiment, the present invention provides a cardiac surgical device of a patient comprising a first arm, a second arm and an actuator, the actuator moving the first arm relative to the second arm. The apparatus further comprises a first blade on a first arm and a second blade on a second arm, the first and second blades having first and second surfaces facing away from each other, the first being And the second surface is adapted to automatically engage tissue or bone by its traction. The device is adapted to be mounted to one of the first and second arms and also includes a stabilization device having a foot, the leg configured to automatically engage the surface of the heart. In a preferred embodiment, the first and second blades are removably coupled to the first and second arms so that the first and second blades can be removed and replaced with replacement blades. This feature allows the surgeon to quickly and easily remove and replace the blade so that the blade can be selected and operated for the particular patient. Thus, the device of the present invention allows the blade to be replaced with various sizes, shapes and materials. Preferably, the arms and blades are made of biocompatible metals for resterilization and reuse, but optionally one or both may be made of plastic or other suitable material and may be disposable, individually packaged and sterilized.

In a second embodiment, the device of the present invention has a receptacle on at least one first and second arm. The suture support is removably mounted to the receptacle so that the suture for pericardial traction or for other purposes is positioned within the suture support and retained therein during the procedure. Preferably, the suture support is constructed of plastic or other disposable material such that the suture support is removed from the receptacle and discarded after use. In general, the suture support includes a plurality of individual sutures, and the turning arm includes a plurality of receptacles to receive a plurality of suture support. In an exemplary embodiment, the receptacle includes a cavity in the arm adapted to receive the suture support. A retention mechanism is provided in the suture support and / or the arm to release the suture support in the cavity.

The suture support includes a body having an outer edge and an inner edge and a retaining structure on the body for retaining the body on the blade of the surgical retractor. At least one channel extends through the body from an inner edge to an outer edge and is adapted to removably receive sutures therein. The clamp is also coupled to the body adjacent the channel and is adapted to release the sutures in the channel. Generally, suture support is located in a bag, pouch or other container and is disinfected from the arm and other portions of the device.

In a further embodiment, an apparatus for surgery on a patient's heart includes a rack and first and second arms mounted to the rack, the first arm being moved relative to the rack and the second arm. It is possible. The first arm is equipped with a first blade, the second arm is equipped with a second blade, and these first and second blades have first and second surfaces facing each other and are spaced apart from each other. The surface is retracted by non-traumatic joining of tissues or bones. A first rail is disposed on the first arm, a second rail is disposed on the second arm, and a third rail is disposed on the rack. The device further comprises a stabilizer coupled to the first rail, second rail or third rail, the stabilizing device having a shape that is shaped to be atraumatically coupled to the surface of the heart. Has

The present invention further provides a stabilization device for stabilizing a site on the outer surface of the patient's heart to facilitate surgery there. In one embodiment, the stabilization device includes a shaft, a leg coupled to the shaft and having a contact surface and non-traumatically coupled to the outer surface of the heart, and the mount attached to the cardiac laparotomy. A first coupling for coupling, a second coupling for attaching to the shaft, a first movable joint interconnected between these first and second couplings, and between the first movable joint and the second coupling It has a second movable joint connected to it. Typically, each of the first and second joints can move around at least two axes of rotation. For example, the first and second joints may include spherical joints or ball-in-socket joints. In one embodiment, the first joint comprises a first hemispherical member centered on a first axis and the second joint comprises a second hemispherical member centered on a second axis, wherein the first and second axes are Mutually non-parallel and usually vertical.

In another aspect of the invention, the device for stabilizing the surface of the heart has a shaft and a leg. The leg has a first arm, a second arm and a space between these first and second arms. Each of the first and second arms has a contact surface for engaging the heart, a base end, a centrifugal end, and a length formed between these base ends and the centrifugal end. The length of the first arm is usually longer than the length of the second arm and is preferably at least 30% longer.

In another aspect of the invention, the leg has a bottom surface with a contact surface lying in the plane. The lateral surface slopes away from the plane to pull adjacent structures.

In another aspect of the invention, the leg has a contact surface with a slot in which blood vessels on the heart are located. The slot is aligned with respect to the central axis, and the legs have a shape asymmetrical with respect to the central axis. In another feature of the invention, the arm is attached to the arm at a position offset from the axis.

In another aspect of the invention, a flexible arm for holding a medical instrument is provided. This arm has a plurality of links, each of which has a through hole. The elongated member penetrates this through hole because the tension on the elongated member locks the link in a fixed orientation. Friction members, such as wire screens, are placed between adjacent links to enhance frictional engagement between adjacent links when the cable is tensioned. A friction member may be applied, glued or embedded on one side of the link to provide a relatively rigid fibrous surface opposite the softer side of the link.

In another aspect of the invention, the arm has a base link that can rotate about an axis about the body. The base link points the elongate member at an angle to the axis, which also displaces at least 0.3 inches (7.62 mm), preferably at least 0.5 inches (12.7 mm) from the pivot axis. The base link typically directs the elongate member at an angle of 45 to 90 degrees relative to the pivot axis.

In another aspect of the invention, a device for stabilizing a medical device includes a base and an arm. The medical device is coupled to the distal end of the arm and pivoted about an axis with respect to the arm, the pivot axis being offset by forming an angle of 70 to 110 degrees with respect to the axis defined by the arm.

In another aspect of the invention, a suctioin member is provided for stabilizing the patient's heart. This suction member has an adaptive skeleton and a coating on the skeleton. The adaptive skeleton has a hinge formed by a thick portion of the coating and usually by an exposed portion of the skeleton, which allows the user to bend and twist the suction member.

The features and advantages of the present invention and additional features and advantages will be better understood from the following description with reference to the accompanying drawings.

The system for performing cardiac surgery according to the present invention is equipped with a retractor for the retraction of sternotomy or thoracotomy. The retractor has a pair of arms facing or spaced apart from each other and a pair of blades mounted to the arms disposed in the thoracic incision. The blades have contact surfaces facing each other and the contact surfaces engage the opposite surfaces of the incision to allow for traction. The arm is mounted in a rack having a plurality of teeth, at least one of which has a pinion gear that engages the teeth on the rack to facilitate movement of one arm relative to each other. In another embodiment a cable drive mechanism different from the rack and pinion is used or the arms are mounted directly on each other or directly on the third member by means of a rotary joint.

In a suitable embodiment, the rail is placed on each arm of the retractor, and when both arms are connected to the rack, the rail is also placed on the rack. Various accessories can be coupled to the rail, including cardiac stabilization devices, cardiac retractors and regulators, CO ₂ blowers, tube cycles, inhalers, vascular clamps, illuminators, catheters and other devices. The placement of the rails permits the sliding of such accessories along the arm for the selected position.

The system of the present invention includes a stabilization device for stabilizing the heart surface. The stabilization device is mounted to the retractor, suitably one of the rails on the arm or the rack of the retractor, in any of a variety of positions. The stabilization device has an axis and a foot, and the leg is formed to non-traumatically couple to the heart surface to stabilize the surface while the heart is beating. The legs have a variety of shapes, including bifurcated forks, partial or complete rings, or polygons, but are suitable for stabilizing the heart adjacent to the anastomotic region to allow anastomosis of the graft in the coronary arteries. The leg has a friction reinforcing surface to enhance grip and minimize movement on the pericardium and the outer periphery is coated with woven, nuring, rough or friction reinforcing materials. In a suitable embodiment, the leg is attached to the shaft by articulation that is or may not be secured by an actuator coupled to the base end of the shaft. This allows the leg to be positioned in various directions relative to the axis along the approach angle and in the location of the anastomosis on the heart.

The stabilization device optionally includes one or more retainers that can be used for placement of the sutures in anastomosis or other procedures. The retainer is suitably positioned on its leg for proximity to the surgical area. The retainers are arranged to hold the seam in tension and are dimensioned for frictional engagement with a clamping device or seam. In an embodiment the retainer is removably attached to the stabilizing device leg to allow the retainer to be removed when there is no need or need to be placed according to the procedure.

The stabilization device is coupled to a mounting base that is attached to the rail of the retractor. The mounting base has at least two movable couplings between the point of attachment to the rail and the point of attachment to the stabilization device, each point having two axes of rotation. Suitably the coupling has a spherical coupling or a coupling in the socket, thus maximizing the number of degrees of freedom available for positioning the stabilization device. The mounting base has a coupling attached to the retractor rail to allow sliding movement and has a securing mechanism for securing the mounting base at selected locations on the rail.

The system has a variety of other parts and accessories useful for cardiac surgery. It has a cardiac retractor with a flexible axis and paddles for engaging the heart. The paddles are suitably coated with gauze or atraumatic friction reinforcement to be gripped on the surface of the heart to facilitate lift and rotation of the heart. The system includes a CO ₂ blower for gas release from the anastomosis area, which allows the anastomosis to dry and remove fluid and debris for the surgeon to see. Suitably the blower is attached to or integrated into the stabilization device to facilitate positioning of the blower outlet near the anastomosis area. Vessel clamps may also be provided and the clamps attached to the rails of the retractor. The clamp is used to temporarily clamp the end of the graft conduit, such as the internal mammary artery, and can be maintained in the surgical field until the surgeon prepares for use. Various other devices are also attached to the rails or other parts of the system, including catheters and surgical instruments as well as lighting, irrigation, suture holding and holding devices.

Referring to the drawings, FIG. 1 shows a first embodiment of a system for performing cardiac surgery in accordance with the present invention. The system includes a retractor 20 having a crossbeam 22, a stop arm 24, and a movable arm 26. The stationary arm 24 and the moving arm 26 have rails 28 and 29 disposed along the upper surface, the rails 28 and 29 having a pair of pairs along the outer and inner upper edges of the arms 24 and 26. It is formed by a pair of opposing side channels 30 forming a lip 32. The stationary arm 24 and the movable arm 26 also have wings 34, 36 extending outwards from the side. Multiple channels 37 extend transversely through the top surfaces of the stationary arm 24 and the mobile arm 26 and are dimensioned to receive sutures therein for the retraction of the pericardium or other tissue as described below. Are arranged.

The movable arm 24 attaches to the carriage 38 which is slidably mounted to the crossbeam 22. The key 40 is rotatably mounted to the carriage 38 and connected to a pinion gear (described below) that engages a rack (described below) on the crossbeam 22. In this way, the movable arm 26 is movable toward and away from the stop arm 24 by the rotary key 40. The stop arm 24 is preferably mounted to the crossbeam 22 in a non-movable manner, in some embodiments, the two arms are moveable to the crossbeam 22 in the manner described above or in any other suitable way. Can be mounted. The crossbeam 22 also includes a pair of side channels 42 at the front and rear edges that respectively form the upper lip 44 and the lower lip 46, so that the stop arm 24 and the movable arm ( 26, a rail similar to the configuration of the rails 28 and 29 is formed.

In FIG. 2, the rear edge of the crossbeam 22 forms a rack 48 having a plurality of linearly aligned gear teeth 50. The key 40 is connected to a pinion gear 52 (shown in phantom) coupled with the rack 48, thus allowing the movement of the movable arm 26 by rotating the key 40. The side channel 42 extends longitudinally through the rack 48, thus forming two parallel rows of gear teeth 50.

In FIG. 1, the first blade 52 is attached to the stop arm 24 and the second blade 54 is attached to the movable arm 26. Preferably, the first and second blades 52, 54 are removably connected to the arms 24, 26 to allow removal and interchange of the various blades. As shown in FIG. 3, the stop arm 24 and the movable arm 26 are shown to be removed from the crossbeam 22 for clarity, where the first and second blades 52, 54. Each has a pair of pins 56 slidably received in the apertures 58 in the stationary arm 24 and the movable arm 26. In this way, blades of various sizes and shapes can be easily interchanged with each other depending on the particular patient and method in which the device is used. The blades 52, 54 have outwardly facing surfaces 55, 57 formed in a shape that automatically engages tissue or bone for contraction.

In the preferred embodiment, the crossbeam 22, the stop arm 24, the movable arm 26 and the first and second blades 52, 54 are to be sterilized and reused after each process. All are made of biologically compatible and sterilizable metals such as stainless steel, aluminum or titanium. However, since any of these components can be made of inexpensive materials suitable for mass production, such as plastic, these components can be discarded after a single use. In another exemplary embodiment, the crossbeam 22 is a metal that can be made available again, while the arms 24 and 26 are made of plastic for single use and each of the crossbeam 22 and carriage 38 are Removably attached. In addition, the crossbeams 22 and arms 24, 26 can be made of reusable metal, while the blades 52, 54 are disposable plastics for single use.

Also shown in FIG. 3 is a stop arm 24 formed to receive a seal stay 62 and a recess 60 on the upper surface of the movable arm 26. Seal stay 62 includes a plurality of slots 66 that align with channels 37 at arms 24 and 26 and a body 64 formed for insertion into recess 60. As shown in FIGS. 4A and 4B, the clamp 61 is connected to the body 64 adjacent each slot 66 and is formed to engage and hold the suture chamber within the slot 66. In a typical embodiment, each clamp 61 includes a leaf 63 extending from the post 65. At the bottom of the body 620, the opening 67 has a bore 69 generally disposed transversely in each slot 66 and adjacent therein. The post 65 is into the bore 69; And the leaf 63 is deflected so as to engage into the opening 67. In this way, the leaf 63 is preliminarily clamped to a clamp position where its outer edge 71 engages the wall of the slot 66. Seated and deflected The outer edge 71 is deflectable in the direction of the arrow 73 to allow the seam to be drawn out in the slot 66, but is deflected back into the seam and engagement to clamp in that position.

In FIG. 1, the system of the present invention also includes a stabilization device 70 for stabilizing the surface of the heart or other tissue during surgical operations. Stabilizer 70 may be mounted to crossbeam 22 or rails 28, 29 by mounting base 72. As shown more clearly in FIGS. 5 to 8, the stabilization device 70 includes an axis 74 having a distal end 76 and a base end 79. Leg 80 is pivotally mounted to distal end 76 by ball joint 82. The leg 80 has an anastomosis site, preferably the surface of the heart on the opposite side of the anastomosis site having a pair of arms 84 parallel to each other and spaced at a distance in the range of about 1-5 cm. It is formed to join. The arm 84 is a flat portion 86 for engaging the heart, an angled portion 88 that is inclined upwardly from the flat portion 86, and the arm 84 is bent and angled or ball jointed. It generally has a proximal portion 90 that may have another suitable shape for attaching a stem 92 connected to 82. The bottom surface of the arm 84 is adapted to engage non-traumatically with a smooth and flat outer pericardium. For example, the bottom surface may be organized with grooves, ribs, knurling, protrusions or other shapes, or they may be foams, Dacron gauze, non-slip material, or rough or woven metal or It may be coated or coated with a friction enhanced material such as a plastic plate.

This material is sufficient to prevent slipping or movement of the foot, but enhances friction with the epicardium to a level that does not injure extracardiac tissue.

In order to lock the leg 80 in a selected position relative to the shaft 74, a rod 89 is slidably disposed in the channel 93 in the shaft 74, as shown in FIG. 7. The rod 89 has a centrifugal end 95 that engages with the ball 97 of the ball joint 82. The actuator on the proximal end of the shaft 74 has a rotary knob 99 having a threaded body 101 housed in a threaded socket 103 attached to the shaft 74. The centrifugal end of the threaded body 101 is attached to the proximal end 105 of the rod 89. In this way, the rotation of the knob 99 remotely drives the rod 89 to achieve intimate locking engagement with the ball 97, thus locking the leg 80 in place.

Stabilizer 70 and leg 80 can have a variety of other structures and shapes. By way of example, the leg 80 may have an annular ring shape or polygonal shape with corners, or may have a simple one heart engaging arm. The stabilization device 70 may further include a suction lumen, a suction port or a cup at the bottom of the leg portion 80 to apply suction to the epicardium to enhance stability and immobility. Other shapes and structures may be provided, such as those disclosed in US Pat. No. 5,807,243, which is assigned to the Applicant, which is referenced herein.

The mounting base 72 has a carriage 90 adapted to slidably engage the rails 28, 29, a turret 92 rotatably mounted to the carriage 90, and rotatably mounted on the turret 92. Mounted clamp 94. The carriage 90 has a channel 96 configured to slide onto the rails 28, 29 or the crossbeam 22, as shown in FIG. 7. The channel 96 has a pair of inwardly projecting lips configured to be positioned in the side channel 30 in the arms 24 and 26 or in the side channel 42 in the crossbeam 22. In order to clamp the carriage 90 to a selected position along the rails 28, 29 or the crossbeam, the carriage 90 has an exterior 102 facing the interior 104 of the carriage 90, and the interior of the carriage 90. It has a living hinge 100 to be rotated in a direction away from. The lever 106 is rotatably mounted to the carriage 90 and has an inclined cam 108, which is coupled to the cam surface 109 on the exterior 102 so that the lever can be operated clockwise. When pressed against the interior 104 (FIG. 8). This locks the carriage at a predetermined position along the rails 28, 29 or crossbeam 22. Rotating the lever 104 in the opposite direction causes the exterior 102 to rotate in a direction away from the interior 104, thus allowing the carriage 90 to rails 28, 29 or crossbeam 22. Slide along or removed from the rail or crossbeam. A fixed finger grip 110 is mounted to the exterior 102 of the carriage 90 to enhance levering during operation of the lever 104.

Referring to FIG. 9, the turret 92 preferably provides rotation about two or more axes. In an exemplary embodiment, the turret 92 includes a spherical joint 112 and a socket 118, the spherical joint 112 having a base 114 attached to a carriage 90 having a hemispherical top surface 116. , And the socket has a cavity 120, whereby the socket 118 can rotate about a number of axes relative to the base 114. In order to secure the socket 118 to the predisposition position with respect to the base 114, a threaded post 122 is fixed to the base 114, extends upwardly through the socket 118, and the socket 118. Is coupled to the threaded cap 124 having a lower end coupled thereto. In this manner, the socket 118 can be locked in a selected position by tightening the cap 124 on the post 122 to force the socket 118 to engage the base 114.

Referring to FIG. 10, the clamp 94 is configured to hold the shaft 74 of the stabilization device 70 or various other surgical instruments and devices used with the present invention. Similar to the turret 92, the clamp 94 preferably rotates about two or more axes. In an exemplary embodiment, the clamp 94 has an inner member 130 and an outer member 132. The outer member 132 has a bore 134 in which a shaft 74 is slidably positioned. The cylindrical extension 136 of the outer member 132 is slidably received in the cavity 138 of the inner member 130. The cylindrical extension 136 has a tapered inner end 140, which couples into the cavity 138. The tapered inner end 140 has an opening 144, and the inner member 130 has an opening 146 through which the rod 148 extends. The rod 148 extends through the socket 118 of the turret 92 and has a threaded end 151 against the ball 150. The threaded knob 152 engages with the threaded end 151, thereby allowing the outer member 132 to be pulled toward the inner member 130 by rotating the knob 152 and thus the bore 143. Allows clamping shaft 74 in) to be pulled. A spring 154 is disposed around the threaded end 151 and engages a knob 152 that pushes it outward. This provides a small amount of clamping force on the shaft 74 even when the knob 152 is loose to prevent the stabilization device 70 from undesirably sliding into the surgical position.

The clamp 94 also includes a spherical joint 156 to provide additional degrees of freedom for positioning the stabilization device 70. The inner member 130 has a hemispherical outer end 158 which is received in a clamp socket 160 attached to the socket 118 of the turret 92. The clamp socket 160 may be a conical, spherical or tapered concave that allows rotation of the inner and outer members 130, 132 around a plurality of axes about the turret 92. The opening 146 in the inner member 130 has a tapered edge and is large enough to allow a wide range of rotational movement of the inner member 130 around the rod 148. The spherical joint 156 clamps the knob 152 in the same manner as the clamp 94, which pulls the rod 148 to force the inner member 130 to engage tightly with the clamp socket 160. .

16 and 19, another stabilization device 200 is shown with a retractor 20. The stabilization device 200 may preferably be used with the retractor 20, but of course may be used with other retractors. Moreover, while the retractor is designed for use in mediastinal sternotomy, the stabilization device 200 can be used with the retractor in other parts of the chest, in particular with a smaller, non-invasive opening without departing from the scope of the present invention.

Stabilizer 200 has a foot 202 coupled to flexible arm 204. The leg 202 can be any leg described herein or any other suitable leg. The flexible arm 204 is formed of a number of links 206 that curve and deform the arm 204. Elongate member 208, such as cable 210 or wire, extends through link 206. Base link 228 initially directs arm 204 in a different direction in a manner described below. When the elongate member 208 is tensioned to the locked position, the links 206 are tensioned together to lock the arm 204 by frictional engagement between the links 206. The tension is reduced to allow the links 206 to slide relative to each other and to provide flexibility to the arm 204 when the arm 204 is positioned. In this way, the arm 204 can be locked in a number of different orientations to reach different parts of the heart.

Stabilization device 200 has an actuator 212, which is preferably a manually operated lever or trigger that is movable from a neutral position (FIGS. 16 and 17) to an operating position (FIG. 18) when operated by a user. Do. The actuator 212 is mounted to a body 205 having a handle 207. As described below, the advantages of the stabilization device 200 of the present invention are the locking and unlocking of the arm 204 relative to the retractor 20, the arm 204 itself, the base link 228 and the leg 202. King may be accomplished by actuator 212. Of course, the actuator 212 can lock a plurality or a few of the members without departing from the scope of the present invention.

16-18, the elongate member 208 has an end 213 attached to the holder 214. The holder 214 is coupled to the actuator 212 by a suitable connection for moving the holder 214. The holder is also coupled to block 215, which is actuated by first and second springs 216, 218, but one or more springs may be used. Arm 204 is normally locked because springs 216 and 218 bias actuator 212 to the locking position of FIG. When the actuator 212 is actuated, the holder 214 is moved in close proximity to reduce the tension in the elongated member 208, thereby unlocking the arm 204.

An advantage of the present invention is that the actuator 212 is typically biased into the position where the arm 204 is locked. When the user attempts to move leg 202, actuator 212 is manipulated to reduce tension on elongate member 208, thereby unlocking arm 204 and leg 202. Next, the leg 202 and the arm 204 are moved to a predetermined position. Next, when the user simply releases the actuator 212, the springs 216 and 218 automatically lock the arm 204, leg 202 and stabilization device 200 against the rail 28 of the retractor 20. . This provides an advantage over many conventional devices that require a positive actuation force to lock the arm 204 and / or the leg 202. During operation of such devices, a user may inadvertently move or displace a portion of the device when the force necessary to operate the actuator 212 is applied. On the other hand, the device of the present invention can lock one or more members by simply releasing the actuator 212.

Referring to FIG. 19, the link 206 has a concave surface 218 and a convex surface 220. Friction reinforcement layer 222 is located between adjacent links 206. The friction reinforcement layer 222 is preferably a screen 224 made of stainless steel mesh, but may be any other suitable structure. When the elongate member 208 is tensioned and the arm 204 is locked, the layer 222 generates a high frictional resistance to sliding between adjacent links 206. The high frictional resistance limits such slippage, reducing the looseness of the arm 204 when the arm 204 is locked. Reducing the amount of looseness of the arm 204 is particularly important when the arm 204 is used to stabilize the coronary artery. Small displacements of the link 206 can cause relatively large displacements at the distal end of the arm 204, which can be problematic when operated on small vessels.

The layer 222 may be attached to the side of the link 206, such as the convex side 22. In this way, the convex surface 22 is harder and more surface shaped than the concave surface 218. The layer 222 may also be a layer embedded in the link 206 or simply attached to the link 206. The layer 222 may be attached in any other way to provide different hardness and / or surface texture. The high frictional resistance generated by the layer 22 reduces the tension required for the elongate member 8 to lock the arm 204. In a preferred embodiment, the tension required to lock the arm is preferably no greater than 889.6 N (200 lbs), more preferably no greater than 667.2 N (150 lbs), most preferably no greater than 533.8 N (120 lbs).

20-24, the tip 226 of the arm 204 is shown. The tip 226 of the arm 204 has a base link 228 that pivots about the body about the first axis 230. Base link 228 guides elongate element 208 along second axis 232, which is offset with respect to first axis 230. The second axis 232 preferably forms an angle of 45 to 90 degrees, and preferably forms an angle of about 70 degrees with respect to the first axis 230. In this way, the base link 228 guides the elongated member 208 along the arc when pivoted about the first axis 230. Of course, the base link also guides the elongate member 208 perpendicular to the first axis 230.

An advantage of the base link 228 is that the arm 204 can be initially directed towards the desired target area. Many conventional arms had to be bent to a relatively large bend radius before the base link 228 made an angle of attack that could be provided over a short distance. The base link 228 extends relatively far from the first axis 230 to reduce the number of links 206, thereby reducing the looseness of the arm and the tension required to secure the arm 204. Base link 228 preferably extends a distance 247 of about 0.762 cm (0.3 in) from first axis 230, and more preferably extends a distance of at least about 1.27 cm (0.5 in). Another advantage of the base link is that position adjustment of the arm 204 can be achieved by simply manipulating the arm 204 and the base link 228.

Base link 228 has a tapered surface 234 mating with a tapered surface 236 on a first tooth 238. When tension is applied to the elongate member 208, the tapered surfaces 234 and 236 engage with each other to secure the base link 228 to the first tooth 238 and prevent the base link 228 from pivoting. do. In this way, the base link 228 is fixed against rotation when tension is applied to the elongate member 208. The tapered face 234 forms an angle of 20 to 60 degrees, preferably 34 to 45 degrees, more preferably about 40 degrees relative to the first axis 230. The spring 240 deflects the surfaces 234 and 236 apart from each other to ensure that the base link 228 pivots freely when the arm 204 is not secured.

With continued reference to FIG. 20, arm 204 is secured to retractor 22 with a locking mechanism 241. The fastening mechanism 241 is preferably fastened and released with the elongate member 208. When the elongated member 208 is tensioned to a fixed position, the tension of the elongated member 208 is transmitted from the base link 228 to the first tooth 238 and attached to the body 205 (the first tooth). Trapping a rail between 238 and the second tooth 243. 22 to 24, the main body 205 is pulled to compress the spring 240 and the first tooth 238 and the second tooth 243 pull the stabilizer 200 into the retractor 20. Enough to release).

25-28, the foot 202 is pivotally and releasably attached to the arm 204 in a manner described below. Leg 202 has a pin 242 that extends to opening 246 in distal housing 248. The distal housing 248 is coupled to the distal link 250. A ball plunger 252 with a ball engages in a circumferential recess 256 of the pin 242. The engagement between the pin 242, the ball plunger 252 and the opening 246 allows the leg 202 to pivot, allowing the user to remove and replace the leg 202 with appropriate force.

Pin 242 is secured against pivoting when arm 204 is secured. Elongate member 208 extends through hole 264 in yoke 266 sliding in distal housing 248. When tension is applied to the elongate member 208, the pin 242 is clamped by the yoke 266, the side 268 of the opening 246 in the distal housing 248 and the ball plunger 252. . The yoke 266 is a spring 270 that makes the yoke 266 contact the housing 248 at the distal end to align the opening 246 and the hole 264 when the tension in the elongated member 208 is reduced. Is biased by A threaded plug 272 is positioned in the threaded recess 274 of the distal housing 248 to adjust the alignment between the housing 248 and the yoke 266 if desired. The opening of the housing is preferably formed small toward the tip to wedge and clamp the pin at the opening 246. As described above, the elongated member 208 is preferably always tensioned until the actuator 212 is driven. In this manner, leg 202 is released and secured with arm 204.

The leg 202 is at an angle to or offset from the axis 260 defined by the central axis 262 of the centrifugal link 250 and the elongate member 208 and is not co-linear. (258) Pivot around. In a preferred embodiment, the axis 258 is between an angle of 70 to 110 degrees with the central axis 262 of the elongated member 208 and / or the centrifugal link 250 which provides an advantage when reaching various parts of the heart. , Preferably forming an angle of about 90 degrees. In other words, the axis 258 is perpendicular to the bottom surface 263 of the leg 202 (see FIGS. 28A and 27B) but is offset relative to the axis 260. The axis 258 around which the leg 202 pivots is preferably outside the defined area between the imaginary lines 259 extending from the first and second arms 263, 265. The first and second arms 263, 265 are preferably parallel but may be angled or applied in various shapes as described below. In other words, the axis 258 is offset between the arms 263, 265 by at least 0.508 cm (0.20 in), preferably 1.016 cm (0.4 in) from the central axis 261. In this way, the connection between the arm 204 and the leg 202 can be more easily located outside the surgical site. Another advantage of the present invention is that the pin 242 can be located on one of the two sides of the leg 202 as shown in FIGS. 27 and 28 and at least removed having a different shape or mounting shape, preferably for the user. And replaceable legs 202 are provided. The pin 242 is preferably mounted to a raised part of the leg 202 which is raised at least 0.127 cm (0.050 in), preferably at least 0.254 cm (0.100 in) from the bottom surface 263. .

29-35, a suction foot 280 is shown. Leg 280 has a suction lumen 281 that provides suction force for attaching leg 280 to the heart surface. Leg 280 has suction recess 282 connected to suction lumen 281. The suction lumen 281 is attached to the leg 280 at the connection 284 and held on the arm 204 with a clip 283. Leg 280 preferably has pins 242 that are held by stabilizer 200 and engage the stabilizer to provide the advantages described above. Of course, leg 280 can be used with other arms without departing from the various features of the present invention.

Leg 280 has an malleable frame 285 that is partially or completely covered by a body 286, preferably made of a polymer. Although any suitable material may be used, this frame 285 is preferably made of 300 Series stainless steel and the polymer is preferably made of polycarbonate. Leg 280 has a flexible tip 287 formed by hinge 290 at a portion of frame 285 (FIGS. 31 and 32). Although the hinge 290 may be a thinner portion of the body 286, the hinge 290 is preferably formed by the exposed portion of the frame 285. In addition, arms 288 and 289 can be unfolded or moved together as shown in FIGS. 33 and 35. 35 illustrates a pin mounted outside the boundary of arms 288 and 289 in the manner described above to provide the advantages described above.

In use, the leg 280 is positioned adjacent to the target site and acts suction to attach the leg 280 to the heart. Then, when the user finds an appropriate position of the leg 280 with respect to the amount of mechanical force that the user wants to exert on the heart, the leg 280 is fixed in that position. Alternatively, leg 280 may be located at a desired location with only mechanical action force with suction force applied later. Finally, leg 280 may provide suction stabilization, but leg 280 may also be used for simple mechanical stabilization.

Tip 287 may be used to retract and stabilize a portion of the heart and other tissues adjacent to the target location. The advantage of tip 287 is that it can provide the necessary displacement in adjacent tissue without changing the ability to stabilize the target site in the desired manner. In this way, it may be retracted to improve adjacent tissue access and / or exposure. For the special use of leg 280, tip 287 may be displaced after leg 280 is positioned at the target location. This gives the user the ability to provide as much amount of retraction as needed and / or additionally to further stabilize.

Of course, optionally, the tips are bent before the legs stabilize for the user attempting various positions until the optimal position is achieved. The tips 287 form a moving portion 292 of the leg 280. The moving part 292 is suitably formed at the tips of the arm, but may be located at any other suitable location on the leg 280, such as on the side of the leg 280.

Although the hinge 290 does not include a suction lumen 281 and the tips 287 do not have a suction recess 282, the suction lumen 281 does not depart from the scope of the present invention. It may extend to the tips 287 with a recess 282 provided in the tips 287. The tips 287 may suitably have a ski-tip, arrow, or V-shape, but of course may have other shapes. The tips 287 extend suitably at least 0.25 inches (6.35 mm), more suitably at least 0.50 inches (12.7 mm) from the hinge 290 to the remote end. Finally, although the hinge 290 is suitably formed by an integral part of the frame 285, the hinge can be mechanically connected.

36 to 40, another stabilization device 300 is shown. The stabilization device 300 may be secured in place with any device, such as flexible arm 204 and retractor 20, without departing from the scope of the present invention as described above. In the embodiment of FIGS. 36 to 40, the stabilization device is coupled to a rigid shaft or arm, but the shaft or arm is flexible, articulated, or hinged.

The stabilization device 300 has a leg 302 having a first arm 304 and a second arm 306. The first arm 304 has a different shape than the second arm 306 and is preferably larger than the second arm 306 to have the advantages described below. The stabilization device 300 is particularly suitable for stabilizing a bent coronary artery in the manner described below, but may of course be used for any other part of the heart. The first arm 304 not only stabilizes the coronary arteries but also constricts other parts of the heart, such as the tip, to improve visualization and / or accessibility. The leg 302 may be made of any suitable material and is made of injection molded plastic or stainless steel. The leg 302 may also be flexible to be shaped by a surgeon. The leg portion 302 has a connector 305 for releasably engaging the leg portion with the arm or shaft.

The leg 302 generally has a convex shape and is formed by the central surface 312 and the side surface 314. The side surface 314 is tapered upwardly away from the central surface 312. The side surface 314 is suitably flat and forms an angle of 5 to 15 degrees, suitably about 9 degrees, with the plane 316 on which the central surface 312 is placed. Although the bottom surface 310 is generally formed by a flat surface, the upper side 314 of course has a curved surface.

The first and second arms 304, 306, and in particular the first arm 304, have a relatively large bottom 310 to stabilize the coronary arteries and constrict other parts of the heart. The bottom 310 of the first arm 304 is suitably at least 30%, more preferably at least 50% larger than the bottom of the second arm 306. Although the surface area is related to the continuous nature of the bottom, the leg 302 may generally have holes or openings while surrounding the surface area described above.

The side 314 further contributes to the stabilization of the heart, but more importantly, the side 314 constricts the heart proximal to improve visualization and / or accessibility. The advantage of the bottom 310 is that it does not compress the heart as much as possible if the side surface 314 does not rise relative to the center surface 312. As the side surfaces 314 are bent, inclined and / or tapered away from the contact surface 312, the side surfaces 314 compress and confine the heart less than otherwise. Although the side face 314 is appropriately tapered from the center face 312, the side face 314 may have any other shape, including a planar or flat concave shape, without departing from the scope of the present invention. .

Friction surface 320 that engages the heart lies within the central surface 312. The friction surface 320 is suitably formed by etching, although the friction surface is formed in any suitable manner or with replaceable elements. The friction surface 320 protrudes slightly below the central surface 312, but generally lies on the same plane 316 as the central surface 312. The friction surface 320 may also be located on both sides of the leg 302.

The second arm 306 suitably has a curved outer edge 322, but may have any other shape. The outer edge 322 has a radius of curvature of about 0.200 inches. The first arm 304 also has an outer edge 324 having a curved surface 326 having the same radius of curvature as the outer edge 322 of the second arm 306. The outer edge 322 of the second arm 306 has a relatively straight extension 328 extending to the remote end 330.

Slot 332 is formed between the first and second arms 304, 306. The slot 332 is suitably tapered towards the remote end 330. The slot 332 suitably forms an angle of 5-20 degrees, more suitably about 10 degrees. Although the slot 332 has a straight side, the slot 332 may also have a curved surface that is tapered remotely.

The slot 302 suitably has an eyelet 334, a hook, a slot, or other suitable structure for receiving a filament 336, such as a suture. The filament 336 is elongated to provide further stabilization of the leg 302. The filament 306 is suitably tied to the retractor 20 but may of course be attached to any other structure.

Other leg portions 302A are shown in FIGS. 41-43, where the same or similar reference numerals are used for the same or similar structures. The first and second arms 304A, 306A of the leg 302A are necessarily identical to the second leg 302 of the stabilization device 300 described above, and the leg 302 is the leg 302. Provides the same advantages as The leg 302 has a connector 305 connected to a shaft or arm. The connector 305 is angled with the central axis 338 suitably 50 to 90 degrees, more suitably 60 to 80 degrees, most suitably about 70 degrees. The leg 302A is used in particular to stabilize the distant branching of the right coronary artery.

The legs 302, 302A are suitably removably attached to the arm or shaft. An advantage of the present invention is that one or more legs 302, 302A can be used to perform multi-vascular coronary bypass. The legs 302 and 302A have different shapes so that other blood vessels and other parts of the heart can be stabilized as the appropriate legs 302. As described in connection with FIGS. 27 and 28, the connector 305 may be placed on opposite sides of the leg 302 to provide suitable arms for various regions of the heart.

In use, the retractor 20 of the present invention is located in the humerus incision as shown in FIG. First and second blades 52, 54 of suitable size and shape are attached to the stationary arm 24 and the movable arm 26. The movable arm 26 is positioned proximate to the stop arm 24 such that the blades 52, 54 can be inserted into the incision. The key 40 is then rotated to remotely move the movable arm 26 from the stationary arm 24, whereby the first and second blades 52, 54 oppose the tissue edges and contract the chest cavity. The incision is enlarged to expose it. An incision is made in the pericardium (not shown in FIG. 11), and the suture is located in the pericardial flap. The suture is formed outside the chest and is located in the slot 66 of the suture stop 62 through the channel 37 and extends until the pericardial flap is formed outside the path for exposing the surgical site of the heart. Next, the pericardial suture may be clamped in place of the suture stop 62.

When it is time to perform the tubular joining, the mounting base 72 of the stabilizer 70 is disposed along one of the rails 28, 29 or at the required position on the crossbeam 22, and the lever ( 104 is actuated to lock the mounting base 72 in place. The stabilizer 70 is then arranged such that the foot 80 engages the epicardium near the junction. Typically, arms 84 are disposed on opposite sides of the target coronary artery aligned with the junction site. Alternatively, one of the arms 84 may be placed in a position that self-engages with the coronary artery upstream of the junction site to occlude the coronary artery during conjugation and provide hemostasis. Once deployed, the stabilizer 70 is locked in place by tightening the cap 124 and knob 152. The stabilizer 70 maintains calm relative to the heart wall in the junctional region, while the heart continues to beat and the remaining heart wall contracts.

12A and 12B show a further embodiment of the stabilizer 70 of the present invention. In this embodiment, the stabilizer 70 includes a pair of suture retainers 164 that may be mounted to the leg 80. Preferably, retainer 164 may be removed from leg 80 such that retainer 164 may be in place or may use stabilizer 70. Retainer 164 has a body 166 and has a plurality of channels 168 in the form of receiving sutures or silastics used in the particular surgical procedure performed. The channels 168 are dimensioned to frictionally engage the seam or silicone material to have sufficient force to hold the material in tension, preferably 0.010 to 0.030 in width, about 0.10 to 0.20 in depth. These dimensions, however, depend on the manner and dimensions of the seam or plastic used. In this way, sutures or plastics can be placed under the target coronary artery to form a sling on one or both sides of the junction, and not only for good exposure of the coronary artery to the surrounding myocardium, but also for hemostasis. Tension may be applied to block the coronary artery. The suture or silicone may then be placed in channel 168 and maintained in the channel under tension during surgery. In a preferred embodiment, retainer 164 has two pins 170 extending from the bottom surface and received in hole 172 of leg 80. Pin 170 has a flange 174 that is inserted into hole 172 and holds this pin 170 in the hole. Retainer 164 and pin 170 may be metal, rubber or plastic.

13 shows a further embodiment of the stabilizer 70 of the present invention. In this embodiment, the blower 176 is connected to the stabilizer 70 to supply gas such as CO ₂ to the surgical site. This not only helps keep this site free of fluid and debris, but also helps prevent the introduction of oxygen into the coronary incision.

Blower 176 includes a shaft 178 through which at least one lumen passes. Preferably, a second lumen is also provided. The inner lumens communicate with at least one hole in the centrifugal end 180 of the shaft 178 and with the inlets 182 and 184 at the proximal end of the shaft 178. Inlet 182 may be connected to a source of gas, such as CO ₂ , while inlet 184 is connected to a salt source for cleaning or misting the surgical site, or a suction source for sucking fluid and debris Can be connected to. Both inlets 182 and 184 may communicate with a single inner lumen in shaft 178, or each inlet may communicate with a separate inner lumen in shaft. At least one clip 186 is connected to the shaft 178 and is removably connected to the shaft 78 of the stabilizer 70. Preferably, the blower 176 has a centrifugal end 180 disposed between the arms 84 of the leg 80 to access the proximal end of the leg to supply or draw fluid from the surgical site without disturbing the joint. It may be arranged to.

14A-14C illustrate a heart retractor that may be used with the system of the present invention. Cardiac retractor 188 has shaft 190 with paddle 192 at the distal end and handle 194 at the base end. Paddle 192 is friction-reinforced and covered with soft absorbent material 196, such as adhesive-reinforced Dacron gauze. Paddle 192 is dimensioned to engage with the outer wall of the heart to roll, lift or push the heart to the required position during surgery, preferably about 1 to 3 inches wide and about 2 to 4 inches across the surface. It is. The cardiac retractor 188 is preferably clamped to the rails 28, 29 or the crossbeam 22 by a mounting base 72 used with the stabilizer 70 as described above. In this way, the cardiac retractor 188 can be used to adjust the heart to the required position and can be locked in place of the retractor 20 to keep the heart in place during splicing or other surgery. . This facilitates conjugation at the sides and back of the heart to enable a multivascular coronary replacement procedure.

15A and 15B illustrate a vessel clamp holder that can be used with the system of the present invention. Vascular clamp holder 200 includes a clip 202 that is removably attached to a commercially available vasculature clamp 203, such as a Forgaty Clamp, as shown. The clip 202 has a slot 204 in the form of receiving a button 206 of the vasculature clamp and has an axial channel 208 through which the shaft 209 of the vasculature clamp can extend. The axial channel 208 has a side hole 210 that allows the shaft 209 to be disposed in the channel, the side hole preferably having a width slightly smaller than the shaft 209 so that once the shaft is inserted Maintained within channel 208. A malleable rod 212 may be shaped to extend from clip 202 to mount 214 and to place clip 202 in the required position. The mount 214 is in the form of being attached to the rails 28, 29 or the crossbeam 22 of the retractor 20 and may be manufactured in a manner similar to that described above for the mounting base 72. However, the mount 214 need not have the same positioning diagram as the mounting base 72, and both spherical joints may be removed. Thus, mount 214 has a carriage 216, such as carriage 90 described above, and is suitable for sliding engagement with rails 28, 29 or crossbeam 22. The carriage 216 has an existing hinge 218 that causes the exterior 220 to rotate relative to the interior 222. The rotary lever 224 engages the camming surface 228 of the exterior 220 to push the lever toward the rails 28, 29 or crossbeam 22 to lock the cam 226 in place. Have

While preferred embodiments of the invention have been described, it will be understood that various equivalents, modifications, additions, and substitutions are possible without departing from the scope of the invention. Accordingly, the above description does not limit the scope of the invention as defined by the claims. For example, any leg described herein may be used with any arm or shaft described herein. The terms "shaft" and "arm" may also be used interchangeably. In addition, the present invention provides several independent aspects and is not limited to one essential shape, advantage or aspect. Thus, each aspect or aspect of the invention may be considered separate from other aspects, advantages and aspects of the invention.

Claims (10)

A shaft; A foot connected to the shaft, the foot having a first arm and a second arm, A space is formed between the first and second arms, and the first and second arms each have a contact surface engaging with the heart, a base end and a centrifugal end, respectively, and a predetermined length is formed between the base end and the centrifugal end. Wherein the length of the first arm is longer than the length of the second arm. The device of claim 1, wherein the first arm is formed at least 30% longer than the second arm. 2. The leg of claim 1, wherein said leg portion has a bottom surface comprising contact surfaces of said first and second arms, said contact surface being generally placed on a plane, said bottom surface being tapered to a distance away from said plane. Having device. Arm; A first leg portion having a contact surface and a slot connected to the arm and engaging with the heart, In the slot, the blood vessels of the heart can be disposed, the slot is aligned with the central axis, the leg portion stabilizes the outer pericardial surface of the heart having a shape asymmetrical with respect to the central axis. 5. The apparatus of claim 4, wherein the first leg has first and second arms of different shapes. 5. The apparatus of claim 4, further comprising a second leg having a different shape than the first leg. Arm; A first leg portion having a contact surface and a slot connected to the arm and engaging with the heart, In the slot a vessel of the heart may be placed, the slot defining an axis and the leg portion stabilizing the epicardium of the heart attached to the arm at an offset position with respect to the axis. 8. The device of claim 7, wherein the leg has a side and the arm is attached to the leg along the side. Arm; A leg portion having a contact surface engaging with the outer pericardium surface; And a coupling for detachably connecting said leg portion to an arm. Arm; A first leg including a contact surface engaging the heart and a bottom surface having a slot, In the slot, the blood vessels of the heart can be placed, wherein at least a portion of the bottom surface is convex, to stabilize the outer pericardium of the heart.