Major advances in this area include the development of a cardiopulmonary bypass support system via peripheral access. The application of suction to the venous drainage has made possible aortic valve and mitral valve surgery via partial sternotomy and minithoracotomy. An earlier breakthrough device in this field was the HeartPort system (developed by Stanford University and New York University Hospital in 1994) which was composed of peripheral vessel-based cardiopulmonary bypass perfusion, an endo aortic balloon occlusion catheter, transvenously placed venting and cardioplegia cannulas, and extra-long operating instruments. Though its early use proved impractical in most cardiac operations, its potential to be less invasive has significantly changed cardiac surgeons’ and medical engineers’ perception of future technologies. Furthermore, the concept of the HeartPort system led to numerous other technological modifications and innovations in the field of less invasive cardiac surgery. Such innovations include: (1) the development of small caliber multistage peripheral venous cannula, (2) the safe application of vacuum-assisted venous drainage to ensure bloodless exposure inside heart, (3) the small thin blade minithoracotomy retractor and atrial retractor, (4) development of the Chitwood aortic cross-clamp, (5) thoracoscopy or endoscopic robotics to assist in the mitral valve repair or replacement, and (6) liberal use of transesophageal echocardiography to guide the insertion of various intracardiac cannulas.

New instruments have also been developed to position the heart and to stabilize and improve the visualization of target arteries. For example, an available left ventricle suction device applies −400 mmHg suction to the left ventricular apex and can hold the heart up in different positions. Now widely used in OPCABG surgery, this device has less of an effect on the venous return as compared with the old “suture retraction” technique. Similarly, a focal myocardial stabilization device has been developed to stabilize segments of target arteries; it has both suction and compressing effects on the topical epicardial tissue and thus significantly decreases the motion of target arteries (Fig. 35.9). An additional noteworthy device is the temporary intracoronary plastic shunt that can be inserted via arteriotomy to maintain blood flow to the distal myocardium during anastomosis, thus avoiding or minimizing ischemia time. Importantly, the use of such a shunt is considered to be crucial when the target artery supplies a large territory of myocardium. In order to facilitate the distal coronary anastomosis during OPCABG, especially in the anatomically difficult-to-reach areas, two innovative distal coronary artery anastomotic devices, C-PortxA (for the open sternotomy approach) and C-Port Flex A™ (for the minithoracotomy or endoscopic robotic approach) (Cardica Inc., Redwood City, CA, USA), were developed and recently approved for clinical use by the FDA. It should be noted that although the early clinical results of such devices are encouraging [22], their clinical adaption has been lackluster.

Different proximal anastomotic devices or hand-sewn facilitators have been developed and used to avoid clamping on the aorta during OPCABG surgery. Unfortunately, the clinical performance of most of these devices has been unsatisfactory, resulting in denial of FDA approval or termination of the products after FDA approval, i.e., the previously FDA-approved symmetry (St. Jude Medical, St. Paul, MN, USA) automated proximal connector being one example.