**3. Heartstring technique**

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

too wide (≤5 cm); otherwise, the hemostasis effect of membrane will be affected. The suction tube of the stabilizer should be connected with the suction device or 50 ml syringe to eliminate possible blood accumulation and keep the operation

• The Enclose greatly reduces the risk of plaque falling off due to the clamping of ascending aorta, and it has fewer requirements for anastomotic area, which merely concerns a relatively soft and healthy area with a diameter about 1 cm.

• Compared with the disposable aortic proximal anastomotic device such as Heartstring, Enclose can support the operation of two or more anastomoses, especially for the aged patients undergoing total vein CABG with severe aortic

• Compared with the first generation of products, Enclose II improved the way of opening the internal aortic diaphragm umbrella: from the hand push knob to the rotary rod operation. This facilitates the operation in the narrow pericardial cavity. Meanwhile, the design of hexagon suture ring is more reasonable

• Enclose requires at least two healthy areas of the aorta: one is the insertion point, and the other is the anastomosis point. Its application is limited to

• A completely bloodless operation field could not be guaranteed. When the

• Due to the technology in the production process, Enclose's membrane might fail to open and need to be replaced. However, the incidence of mechanical

• Enclose II is relatively expensive, which to some extent increases the medical

Cerebrovascular complications are one of the most common complications after CABG. The main reasons could be mainly attributable to the atherosclerotic plaque or new thrombus falling off and embolism of ascending aorta or carotid artery during and after operation [14]. Other possible causes might be the excessive anticoagulation, or the sudden rise of blood pressure, causing the rupture and hemorrhage of cerebral vessels [15]. Atherosclerosis is a group of systemic diseases, and vascular endothelial dysfunction has been widely considered as the most important initiating link in its process and exists in the whole process of atherosclerosis. Atherosclerosis is a chronic, progressive and multiple endovascular disease, involving many large and medium-sized arteries. For patients with severe coronary atherosclerosis, especially those over 70 years old, the incidence of aortic atherosclerosis or calcification

than the rhombic suture ring from the previous generation.

suture is too tight, there will be different degrees of bleeding.

patients with large-area diffuse calcification aorta.

**2.4 Advantages and limitations of Enclose technology**

**262**

field clean.

*2.4.1 Advantages*

atherosclerosis.

*2.4.2 Limitations*

failure is very low.

expenses of patients.

**2.5 Clinical significance of Enclose technology**

The Heartstring proximal anastomosis system is suitable for the proximal anastomosis of the graft and the aorta without the use of aortic clamp in CABG [16–17]. The first generation of Heartstring proximal anastomosis system was launched by Guidant Company in 2002 and the most commonly used Heartstring III was launched by MAQUET after continuous technical improvement. The American Thoracic Surgery study [18] of 1380 patients with aortic calcification found that the predicted risk of stroke in patients using Heartstring was reduced by 44%, especially in patients with aortic calcification above grade II (**Figure 3**).
