Patent Publication Number: US-2020281614-A1

Title: Pericardial gripper and method of implanting a temporary cardiac assist system

Description:
TECHNICAL FIELD 
     The disclosure relates to a method for gripping the pericardium using at least one device which comprises at least one outer part and at least one inner part. 
     BACKGROUND 
     The heart is a necessary organ for the viability of different species. The human species also uses its periodic contracting and relaxing, beating, for pumping blood through its body. Science models its service as a positive-displacement pump and parameterizes its rhythm therein as the opening and closing of valve flaps in order to understand its operation. 
     Cardiology is the science of the heart&#39;s activity in structure and function, as well as of its activity in interaction with other organs. It also includes dysfunctions of the heart. As a result of aging, treatment or disease, the heart&#39;s ability to beat may be reduced. Causes of this so-called cardiac insufficiency may be high blood pressure, heart valve defects or calcification of coronary vessels. 
     In her master&#39;s thesis: “Entwicklung eines Herzbeutel Zugangs für die Einbringung eines das Herz unterstützenden Implantats” (“Development of a pericardium access for the insertion of a heart-supporting implant”), autumn 2017, Department of Medical Technology, Technical University of Berlin (Reference 1), Sarah Zubke explains the basics of cardiac insufficiency. 
     According to her work, terminologically, insufficiencies are defined according to the European Society of Cardiology by differentiating three forms, the so-called: systolic and diastolic insufficiency as well as cardiac insufficiency with middle left ventricular ejection fraction. According to the work of Ms. Zubke, in 2014, according to the Federal Statistical Office of Germany, about 430,000 patients with cardiac insufficiency were recorded wherein about 36,000 died of it. 
     Today, a lot of measures are used to treat cardiac insufficiency. Known elements of this set, sequenced along a scale, are: heart transplantation, pacemakers or drugs. The sequence decreases with the severity of cardiac insufficiency. 
     Therapy with cardiac support is also an element that may be sequenced along the scale next to the element heart transplantation. Both elements differ in the criterion of their duration of use. Cardiac support therapies are configured to last for hours or days, whereas heart transplantation-based therapies last for months or years. 
     With regard to cardiac support, the state of the art includes: intra-aortic balloon blood pumps, percutaneous intravascular pumping systems—so-called blood pumps or percutaneous sheathing devices. 
     U.S. Pat. No. 6,544,216 B1 teaches an intracardiac blood pump. It has a tube-like embodiment, its first end in the right atrium and its second end in the pulmonary artery—operated through the pulmonary heart valve. One section of its tube-like embodiment includes a pumping section. Therefore, the intracardiac blood pump pumps blood from the right atrium into the pulmonary artery during surgery. 
     Blood flows through the pumping section, enters it radially at the first end, but leaves it axially at the second end. 
     Because blood flows through the pump section, surface effects occur between individual blood cell surfaces and internal pump section surfaces. These surface effects, for example friction, damage the blood cells. A disadvantage of the intracardiac blood pump is therefore its blood cell-damaging effect. 
     In WO 2017/134304 A1 a technique of a pump supported by passive magnetic action is described. This blood pump delivers fluid from its inlet to its outlet by building up a delivery pressure. The pressure force of the delivery pressure overcomes a closing force closing the blood pump. 
     The sealing force results from a passive magnetic bearing of the rotor in the blood pump, whereby the rotor is at least passively magnetically attracted or repelled axially in one direction. Because it is magnetically attracted or repelled, the rotor is forced into a seat. 
     The compressive force results from the transfer of rotational energy by means of blades from the rotor to the blood surrounding it. As it rotates, blood is scooped in one direction—a flow of blood—and pushed forward. 
     The blood pump pumps when the direction of the pressure force opposes the direction of the sealing force and is greater in strength. 
     The blades do not only touch the blood, but their rotational speed creates friction between the surfaces of the blood lines and the blade surfaces. Thus, they endanger the blood cells. 
     A market participant describes on her webpage http://www.cardiobridge.com/technology/ on Sep. 14, 2017 a technology called “10E-Reitan Catheter”. According to her own information, this is a subcutaneous and intra-arterial short term intraaortic percutaneous circulatory support. In operation, the product is inserted into the pulmonary artery and is spaced apart from the heart. The product consists of a wire net stretched over a propeller in which a propeller rotates. The wire net balloons the surrounding section of the pulmonary artery. The propeller lies in the wire net at right angles to the direction of blood flow. Its rotation thus accelerates the blood flow by transferring kinetic energy to it. The higher the transfer of kinetic energy, the higher the substitution of the heart&#39;s pumping capacity. 
     However, the propeller is in direct contact with the blood, resulting in the destruction of blood cells. 
     All blood pumps presented here have the disadvantage in common that they damage, usually destroy, blood cells. This disadvantage is known in the state of the art as the so-called haemolysis rate. It describes the ratio of destroyed to non-destroyed blood cells or pumped blood volume. 
     The EP 10 2008 018 919 A1 suggests a sheathing device to support and/or take over the pumping function of the heart. This is intended to apply directed cyclical compression and decompression to the heart in cases of need, for example during acute cardiac insufficiency, in order to support the heart&#39;s pumping action. The idea behind applying the directed cyclical compression and decompression is to enclose the heart with a mantle whose mantle volume is compressible. Its volume changes are then applied to the heart surface as a directed force. To grasp it, it requires the mantle to be inserted into the patient. This condition is further elaborated in the proposal, in which the compressibility of the mantle is used to make the conembodiment device foldable. This embodiment is less invasive and less demanding. 
     Its essential functional requirement to encase the heart is its essential disadvantage. A sheathing in case of need means a sheathing under time pressure and under unfavourable conditions. In practice, both make it difficult to apply the conembodiment device correctly. 
     In the state of the art, various aids are known which are available to a person treating a patient, for example, a doctor treating cardiac insufficiency. A variety of assistive devices help the physician in an operation to move medical devices such as blood pumps to their destination in the human body. 
     Known aids are scalpels, cannulas or forceps. 
     Scalpels are very sharp blades. They are guided by the doctor by hand and force hand-guided, free-form incisions. If a scalpel is used to reach a deep-seated destination in the human body, an exposed blade must be guided through the body by the doctor. 
     Its sharp blade is a disadvantage of the scalpel. It exposes the human body to the risk of dangerous cuts. 
     Cannulas are medical needles, including hollow needles and hypodermic needles. They are preferably used to inject liquids into or withdraw liquids from the human body. They are inserted into the body by pushing them through the skin, internal membranes, tissues, tissue sections, organs. This advance is made possible and facilitated because the needle tip is sharp, usually ground. 
     Its sharp needle tip is also a disadvantage of the cannula. If the cannula is advanced too deeply into the body—for example beyond its destination—important parts of the body are injured unintentionally, sometimes unnoticed. 
     Medical forceps help the doctor to hold on to body parts. If they are gripped incorrectly or too tightly, they have the disadvantage of tearing tissues. 
     The anatomy differentiates the heart from its surrounding pouch. This pouch is called the heart pouch, in the doctor&#39;s terminology the pericardium. 
     An overview of pericardial diseases is given in the ESC Guideline “Guideline on the Diagnosis and Management of Pericardial Diseases”, European Heart Journal 2004. 
     A minimal opening of the pericardium, its punctual piercing or puncturing is called pericardial puncture. It differentiates the so-called wet from dry puncturing. For this purpose, the presence or absence of a fluid or fluid cushion between the heart and the pericardium, in lingua medicus effusion, is the criterion. 
     If an effusion is present so that a physician punctures the effusion from the outside through the pericardium, the physician punctures wet. If there is no effusion, i.e. the pericardium is close to or on the heart, the physician punctures dry. 
     Today the heart is treated mechanically if the pericardium may be punctured wet. This is the case when the effusion fills an approximate minimum volume of about 25 ml, because this minimum volume compensates for a possible misalignment of a treatment tool—a cannula or needle—by the treating physician. The effusion therefore protects against a certain degree of slipping, slipping off or misalignment in the moment of the puncture. 
     Therefore, when puncturing, an X-ray imaging technique is usually used, firstly to visually follow the advance of the treatment tool, and secondly to detect the moment of puncture. 
     For this purpose, e.g. when using a needle, an X-ray contrast medium is applied through the tip. This forms a liquid point in front of the needle tip within a tissue, at the moment of puncture, and a veil in the cavity of the pericardium. If a liquid point melts into a veil, it is possible to distinguish in the X-ray image whether the pericardium is punctured or not. 
     In EP 1 956 963 B1 an arrangement for guiding instruments is explained. As examples of instruments, it refers to endoscopes, removal or assembly tools or tools for optical imaging of selected areas in cavities. The arrangement is intended to particularly enable instruments to be guided relative to at least part of the walls of a cavity in general, and medical or veterinary instruments to be guided in cavities in living organisms. It solves the special case by segmenting the arrangement so that it is a link chain whose joints are connected to each other in a manner that allows them to be bent and the length of individual segments or several connected segments to be varied. Because of this solution, there is the benefit in making it possible for the first time: defined examinations, reliable punctures or other manipulations. 
     According to an online innovation report, “Marburger-Attacher revolutionizes pericardial puncture”, dated 9 Mar. 2005 on a subpage of the website “www.innovation-report.de”, the so-called Marburger-Attacher enables a user to “perform targeted and signal-monitored minimally invasive manipulation of organs”. 
     The Marburger-Attacher embodiments the phenomenon for puncturing the pericardium in a protected space, by a volume that is cut into one of its ends, into which pericardium is sucked, so that by holding it, due to this suction force, the pericardium may be turned away from the heart in order to puncture it safely. 
     Creating a protected space for a puncture is complex. Providing such a space results in providing its volume. This makes the Marburger-Attacher large and unwieldy. 
     In summary, the state of the art knows of mechanisms of action that are based on suction of the pericardium. 
     The disadvantage of the state of the art is that it requires a more invasive access to the heart. 
     In U.S. Pat. No. 9,585,689 B2 a teaching of an access—an airlock is published. This offers a defined passage generally through a biological membrane,—and in detail through the pericardium. As an outer part, the airlock comprises two tubes inserted into each other and an inner part guided in the outer part. It is pushed into a puncture, because in a first step it is punctured with a needle, in a second step a wire is passed through it, and in a third step: inner part, inner and outer tube,—the airlock were passed over the wire, because the wire is tunnelled through the airlock. The initial pushing of the airlock into the puncture is followed by the fixation of the pericardium in the airlock. A distance between the inner and outer tube may be reduced since the inner tube may be retracted axially against the direction of advance. A reduction results in a contraction of the groove because this distance describes a groove width. The groove will pinch the pericardium surrounding the puncture when the groove is reduced because the groove is intended to be in the puncture. 
     Use of the airlock requires a pericardial puncture. Unfortunately, the airlock has no functionality to puncture the pericardium, so the puncture must be performed with a second tool. Introducing a second tool into the human body is introducing a second source of contamination. This results in a disadvantage of the closest state of the art, it increases the risk of infection. 
     The use of the airlock also requires its fixation. Since this is the result of pericardial entrapment in a groove, the airlock must be manipulated by a treating person until the groove is in the puncture. Manipulation in the confinement and darkness of the human body through a minimally invasive incision is complicated and endangers the success of the therapy due to this complexity. 
     After using the airlock, it must be removed from the human body. The airlock must be pulled, regularly. Pulling out the sheath causes the puncture to tear open because pericardium is in the groove when the sheath is used correctly. 
     SUMMARY 
     The object of the disclosure is to create a gentle introduction of medical devices into human cavities. It is solved by a method for gripping the pericardium with at least one device, the device comprising at least one outer part and at least one inner part, in which a body opening is created, wherein the device is advanced through the body opening in the direction of the pericardium until at least one end of the device touches the pericardium or the heart or a layer arranged on the heart, so that then the inner part is moved until at least one outer part end and/or inner part end is located at the pericardium, the object is solved by gripping the pericardium with at least one outer part end and/or inner part end. A pericardial gripping device comprising at least one inner tube and at least one outer tube, wherein the outer tube has at least one outer diameter and wherein the inner tube has at least one inner diameter, the outer diameter being larger than the inner diameter and the inner tube having at least one inner tube end on at least one inner tube end, and wherein the inner tube end surface has at least one first surface structure and wherein the outer tube has at least one outer tube end surface on at least one outer tube end, and wherein the outer tube end surface has at least one second surface structure, and wherein the first surface structure and the second surface structure are different, solves the object by movably arranging the inner tube in the outer tube. 
     First advantage of the method: In her master&#39;s thesis—Reference 1—, Ms. Sarah Zubke works out the significance of speed for the patient&#39;s well-being of an introduction of medical devices using the example of an introducer set. According to her results, devices for inserting guide wires are unsuitable for clinical practice if they do not allow insertion within 55 minutes, preferably 30 minutes, especially 10 minutes. Her results thus make the insertion speed a criterion for evaluating proposed solutions to the state of the art. A reversal of Ms Zubke&#39;s results thus allows the conclusion to be drawn that a procedure and a device gain in value if they allow the introduction of medical devices into the pericardium in a short period of time—the shorter the better. 
     By way of the disclosed method, a medical device may be quickly introduced into the pericardium. Its uncomplicated method steps and the method step of grasping the pericardium both contribute to this speed. 
     By penetrating the human body with at least one end of the device until it touches the pericardium, the heart or a layer on the heart, all three of them may be quickly located. penetration becomes particularly rapid because it is even easier for a person undergoing treatment if the device is rigid so that the end of the device may be inserted through the human body. 
     Among others, the following definition may be made as infiltration time: The time between the moment when a human body is opened and the moment when a temporary cardiac assistance system is put into an intended operation. 
     The second advantage of the method: Gripping the pericardium, the heart or a layer lying on top of the pericardium with at least one external end may be done quickly. 
     Third method advantage: As it is characterized by gripping pericardium, it has the advantage of being able to distance gripped pericardium from the heart. The spacing opens a space between the pericardium and the heart into which a puncture or cutting tool may enter after penetrating the pericardium without the penetration directly endangering the heart by the penetration of the tool, because the tool penetrates indirectly into the space. Vice versa, the fourth advantage of the method is therefore the increase in treatment safety. 
     Also, a device for grasping pericardium comprising at least one inner tube and at least one outer tube, wherein the outer tube has at least one outer diameter and wherein the inner tube has at least one inner diameter, the outer diameter being larger than the inner diameter and the inner tube having at least one inner tube end surface on at least one inner tube end, and wherein the inner tube end surface has at least one first surface structure and wherein the outer tube has at least one outer tube end surface on at least one outer tube end, and wherein the outer tube end surface has at least one second surface structure, and the first surface structure e and the second surface structure are different, solves the object by movably arranging the inner tube in the outer tube. 
     First device advantage: The device follows the principle of “assembled tubes, or assembled hoses”, one of whose deductive is their small volume. The existence of a small volume device according to the disclosure may lead a treating person to a behavior of minimally invasive opening of the human body. Leading the treating person to this patient-friendly behavior is therefore the first advantage of the device. In addition to a number of known secondary advantages, for example rapid wound healing of a minimally invasive procedure, its primary advantage is its rapid execution. 
     Second advantage of the device: Surprisingly, the device further protects a patient because it allows a grip in the first attempt. This advantage is based on two premises. The first is that it may be used to grasp all kinds of human tissue. The second is that multiple grasping of human tissue is stressful for a patient, i.e. one-time grasping is gentle on human tissue. If a type of tissue has been grasped with the device and a single grasp is generally gentler, the treating person does not have to grasp a certain type of tissue. 
     Third advantage of the device: When using the device, the displacement of fat is of great benefit. 
     In a preferred embodiment, an outer part is twisted against an inner part to grip the pericardium. The twisting is carried out by the handling of a treating person, i.e. in a first consequence it is mechanical. In a second consequence, it is therefore a grasping, and is thus a mechanical grasping in the overall consequence. This phenomenologically allows a feedback to the treating person. The advantage of mechanical grasping is its inherent feedback of the gras during grasping and the gripping in the grip. This advantage, the tactile feedback, promotes safe and fast work by the treating person. 
     In a preferred embodiment, at least one outer tube is twisted against at least one inner tube to grip the pericardium with the outer part. Due to this type of gripping, the gripping gains in positional or positional constancy. A requirement of this type of gripping is fulfilled when an inner part positions the device opposite the pericardium. Then, assemblies of the outer part—which is positively guided by the inner part—may be twisted several times against each other, because the constancy of the position of the device is not caused by the outer part, but by the inner part. 
     In a preferred embodiment, a first outer part end surface is twisted against a second outer part end surface for gripping the pericardium, i.e. a first end face is twisted against a second end face. 
     When surfaces rub against each other, they are engaged. This engagement is the result of a—microscopic—entanglement of their surface structures. The strength of the engagement, the holding force of the grip is proportional to the catching. Due to the upper set: the more gradual the twist, the stronger the snagging, and the lower set: the stronger the snagging, the stronger the holding power, closes the figure in ponens mode: the more gradual the twist, the stronger the holding power. The advantage of twisting outer part end surfaces is an increase in holding power. This increase is further enhanced when the outer part end surfaces are twisted against each other. 
     If surface structures are introduced into the outer part end surfaces, the holding force is further increased. It is advantageous if grooves, scores, flutes or cables are incorporated into the surface. Their structure may be periodic, fanned or overlapping. 
     Because the outer part end surfaces are located at one end of the outer part, the geometry of the outer part end surfaces may be changed easily and advantageously. This change may promote an increase in the holding force if a position angle between the surface vector of an outer part end surface and the outer part is increased or decreased. 
     In a preferred embodiment, the gripped pericardium is mechanically lifted from the heart by the device. 
     Lifting spaces apart the heart from the pericardium. This safety distance secures the heart against intentional or unintentional penetration of a puncture or cutting tool by a treating person. 
     In a preferred embodiment, the inner part is removed from the device. 
     Removal opens a passage in the outer part, providing access to the pericardium. The advantage of this access is that tools may be passed through it to the pericardium. If these tools are puncture or cutting tools, the pericardium may be manipulated to open it. 
     The opening may be shaped as a dot, a slot, or a star, made by cutting or punching. 
     The opening advantageously allows dry punctuating by mechanical lift-off 
     In a particularly advantageous embodiment, a punching tube is fed to the pericardium. One end of the tube is sharpened in a favourable continuation to the blade, so that a round section may be punched from the pericardium into the pericardium. Punching has the advantage of forming a clean cutting edge. This prevents further tearing of the pericardium. 
     If a tool is inserted through the device into the heart during the procedure, different measures may be taken depending on the tool. 
     If a signal is generated by the device during the procedure for those cases in which it touches the pericardium or the heart, its signal generation positively contributes to the speed of the procedure. A signal to an attending person guiding the device is suitable to induce the attending person to change the action, to move the outer part over the inner part. The signal or a signal display may be automatic, or semi-automatic, optical, acoustic or haptic. If different signals, e.g. an acoustic signal, such as a beeping sound, and a haptic signal, such as a shaking or pressing, are combined, the signal effect is increased so that the procedure may be carried out even faster and more safely. Combining signals increases the redundancy. Depending on the signal, an automatic stop or automatic engagement of a brake may also be provided. This has the advantage that a process point may be displayed from which increased care must be taken. It is of particular advantage if an automatic stop is triggered 1 mm before the pericardium. The safety of the method is further increased if at least one camera that is able to view the pericardium is part of the method. A mechanical brake, e.g. a detent or spring brake, or an electronic brake, e.g. an electromagnetic brake, further increases safety. 
     If the pericardium is gripped by at least one tooth on the device during the method, it may be twisted behind the teeth by slightly swiveling the device or its parts. 
     In a preferred embodiment of the device, the inner tube is rotatably mounted in the outer tube. 
     By turning or partial turning, i.e. by pivoting the inner tube in relation to the outer tube, its end faces are swiveled against each other. This pivoting results in the advantageous gripping of the pericardium, if it is arranged in front of or against the end faces. 
     In a preferred embodiment of the device, at least one inner part is present, whereby the inner part is movably arranged in the inner tube. 
     If the inner part, e.g. a probe or a cannula, may be pushed through the inner tube, the inner part may be gently advanced up to the pericardium, where it may be used according to its function, e.g. sensing, gripping, sealing or closing. The advantage of a movable arrangement is that it allows for a tool change. In the example of closing, stapler, suture and heat or laser tools may be used one after the other to close the opened pericardium. 
     In a preferred embodiment of the device, at least one sensor probe is present in at least one through hole of the inner part. 
     It is advantageous if this probe provides a haptic signal in the moment the probe reaches the pericardium. 
     In a preferred embodiment of the device, at least one spring element is arranged between a surface of the inner part and a surface of the sensor probe head. 
     This has the advantage of buffering contact between the probe head and the pericardium. 
     If at least one tube is flexible, especially a hose, the entire device is flexible. This simplifies handling of the device. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  shows a device for grasping the pericardium of a patient in a schematic sectional view. 
         FIG. 1 a    shows a device for grasping the pericardium of a patient in a schematic sectional view from the side. 
         FIG. 1 b    shows an outer part of the device in a schematic sectional view from the side. 
         FIG. 1 c    shows an inner part of the device in a schematic sectional view from the side. 
         FIG. 1 d    is a detailed view of a backup. 
         FIG. 1 e    is a view along the section E 0 -E 0 . 
         FIG. 2  shows different views of an outer part end of the device for grasping the pericardium of a patient. 
         FIG. 2 a    is a detailed view of an outer part end in a schematic sectional view from the side. 
         FIG. 2 b    is a sectional view of an outer part end from right to left. 
         FIG. 2 c    is a sectional view of an outer part end from left to right. 
         FIG. 3  shows a first preferred continuation of the device for grasping the pericardium of a patient as a so-called “serrated gripper”. 
         FIG. 3 a    is a schematic view of a first alternative of the “serrated gripper” from the side. 
         FIG. 3 b    is a schematic view of a second alternative of the “serrated gripper” from the side in schematic section. 
         FIG. 3 c    is a schematic view of a further configuration of the “serrated gripper” from the front. 
         FIG. 4  shows a second preferred continuation of the device as a so-called “groove gripper”. 
         FIG. 4 a    is a schematic view of the different alternatives of the “groove gripper”. 
         FIG. 5  shows a schematic flow chart of a procedure for grasping the pericardium of a patient. 
         FIG. 6  is a schematic representation of the positions of the device for grasping the pericardium of a patient in its use. 
         FIG. 6 a    shows a position of the device in the human body. 
         FIG. 6 b    shows a position of the device for grasping the pericardium of a patient in which one of its ends touches the pericardium. 
         FIG. 6 c    shows a position of the device for grasping the pericardium of a patient in which one of its outer part ends touches it. 
         FIG. 6 d    shows a layer of the device for grasping the pericardium of a patient, whereby the pericardium is gripped with an outer part end. 
         FIG. 6 e    shows an alternative embodiment of a device according for grasping the pericardium of a patient as a serrated gripper. 
         FIG. 6 f    shows an alternative embodiment of a device for grasping the pericardium of a patient as a serrated gripper in an insertion position. 
         FIG. 6 g    shows an alternative embodiment of a device for grasping the pericardium of a patient as a serrated gripper in one grip position. 
         FIG. 7  shows a device for grasping the pericardium of a patient in a position of use with seals. 
         FIG. 8  is a detailed view of a device for grasping the pericardium of a patient. 
         FIG. 8 a    is a detailed view of a device for grasping the pericardium of a patient in a gas permeable position of use. 
         FIG. 8 b    shows a detailed view of a device for grasping the pericardium of a patient in a gas-tight position of use. 
         FIG. 9  is a detailed view of a device for grasping the pericardium of a patient. 
         FIG. 9 a    is a detailed view of a device for grasping the pericardium of a patient in a gas permeable position of use. 
         FIG. 9 b    is a detailed view of a device for grasping the pericardium of a patient in a gas-tight position of use. 
         FIG. 10  is a schematic representation of layers of a device for the insertion of an implant. 
         FIG. 10 a    is a schematic view of an open treatment site. 
         FIG. 10 b    is a schematic view of an open treatment site with a soft tissue retractor. 
         FIG. 10 c    shows a tensioning of a soft tissue retractor. 
         FIG. 10 d    shows a sealed pericardial opening. 
         FIG. 11  is a schematic diagram of the positions of an implant. 
         FIG. 11 a    shows a layer of an implant within the device for grasping the pericardium of a patient. 
         FIG. 11 b    shows a position of an implant within the device for grasping the pericardium of a patient. 
         FIG. 11 c    shows a layer of an implant. 
         FIG. 11 d    shows a detail with an implant anchor. 
         FIG. 11 e    shows a detail with an implant anchor. 
     
    
    
     DETAILED DESCRIPTION 
       FIG. 1  shows a schematic sectional view of a device for grasping the pericardium of a patient. 
     Phenomenologically, the device teaches how to grip human tissue (not shown) by stretching a section of tissue (not shown). It teaches tensioning as the result of a conditional displacement of at least two different tissue subsections (not shown). The different tissue subsections (not shown) are to be moved in different directions in order to tension them together. The more the displacement, the more the tension, the stronger the grip of the device. Because the application of a force precedes each displacement of a tissue sub-section (not shown), the gauge of the device may also be understood as a phenomenon that describes the application of at least two forces in different directions to a defined surface element. 
     The phenomenon is sensory determined as a grasping. Grasping is a tensioning of tissue as a result of its multiaxial displacement. Its sub-phenomenon, uniaxial displacement of tissue sections by at least two rotations, is referred to as “ring gripping”. Ring gripping may involve fixing and pulling, holding and retracting, or temporary joining and forced guidance. 
     In  FIG. 1 a   , the device  10  is shown in a preferred embodiment as a “ring gripper”. 
     In a preferred embodiment, the “ring gripper” comprises at least one outer part  40  in which an inner part  90  is guided. The outer part  40  in turn comprises an outer tube  50  and an inner tube  70 . Both the outer and the inner tubes  50 ,  70  are circular in cross-section. 
     In the preferred embodiment, the tube  50  and the inner tube  70  may also be hoses (not shown) or parts of hoses (not shown), so that an inner hose (not shown) is guided in an outer hose (not shown). In the embodiment of a hose, the freedom of movement for the patient is increased. As a shaft, the hoses may have a flexible shaft. 
     In its first sub-embodiment the outer tube  50  is manufactured as outer knurling wheel  60 , the inner tube  70  as inner knurling wheel  80 . The phenomenon of ring gripping may be determined in this sub-embodiment because it links at least two partial functionalities: contacting the outer part  40  with the pericardium  34 ; ring gripping the contacted pericardium  34 . A (partial) rotational twisting of the outer knurling wheel  60  against the inner knurling wheel tensions tissue sections (not shown) of the pericardium  34  at the site of contact above the heart  31 —the direction of rotation of the outer knurling wheel (not shown) counters the direction of rotation of the inner knurling wheel (not shown). 
     In its first alternative embodiment, the outer part has an outer guide (not shown) instead of an outer tube, for example an outer linear guide (not shown). Preferred linear guides include profile rails with a U, V or T profile. 
     In its second alternative embodiment, the outer part includes both an outer tube and an inner tube or a combination of both in the form of a polygonal tube (not shown). A polygon tube is polygonal in its cross-sectional profile. Preferred cross-sectional profiles for polygon tubes are square, pentagonal, hexagonal or octagonal profiles. 
     In the preferred embodiment, all assemblies and components, especially the outer knurling wheel as well as the inner knurling wheel, are made of aluminum or titanium. Preferably they are all milled or turned from an aluminum or titanium block. In further alternatives, they may all be made of steel or other biocompatible materials. Biocompatible materials according to ISO 10993,—besides steel especially also plastic—are preferred. 
     In the preferred embodiment, an inner tube  70  is mounted in the outer tube  50 . The outer diameter of the outer tube (cf.  FIG. 1 b   ) corresponds to the outer diameter of the inner tube (cf.  FIG. 1 b   ), so that the outer surface of the inner tube  70  together with an inner surface of the outer tube  50  guides the inner tube in the outer tube. In a further embodiment, partial surfaces lead the tubes to each other. They may be at least one mantle surface section (not shown) of the inner tube  70  or at least one inner surface section (not shown) of the outer tube  50 . In a further embodiment, the inner tube  70  is biaxially guided in the outer tube  50 . The axes lie in the longitudinal and circumferential direction of the ring gripper  13 , so that the inner tube  70  may be manipulated in two degrees of freedom relative to the outer tube  50 . 
     In the preferred embodiment, an inner part  90  is loosely and unidirectionally mounted in the outer part  40 . The inner part  90  is thus movable in the outer part  40  in axial direction  15 . The guide forces the inner part  90  in the outer part  40  to move in axial direction  15 . 
     The preferred embodiment in  FIG. 1 a    shows the principle of “assembled tubes”. The ring gripper  13  is formed by inserting its inner part  90  into the outer part  40 . The outer part is formed by inserting the inner tube  70  into the outer tube  50 . Thus, the phrase “all components are plugged together” applies. Because inner part  90  and outer part  40  are also a type of tubes, the phrase “all components are tubes” applies. Thus, in the mode ponens, the phrase “all tubes are plugged together” applies. This principle may also be described as “tubes plugged together”. 
     In its second sub-embodiment the inner part  90  is formed as pin  100 . At least one through hole  102  is made in pin  100 . It is preferably drilled over its entire pin length  109 . A pin hole  106  is countersunk into the pin tip  105 . The pin  100  has an outer pin diameter  101 . 
     In the preferred embodiment, the inner part  90  includes a probe. This is divided into a probe shaft (see  FIG. 1 c   ) and a probe head (see  FIG. 1 c   ). The probe shaft (see  FIG. 1 c   ) is inserted in the through hole (see  FIG. 1 c   ) of the inner part  90 . It is secured against slipping out in the axial direction  15  towards the tip of the device  13  by means of a securing device  130  on the side of the ring gripper  13  opposite the tip of the inner part. 
       FIG. 1 b    shows a schematic sectional view of an outer part  40  of the device from the side. 
     In the preferred embodiment, the inner tube  70  is inserted into the outer tube  50 , an inner knurling wheel  60  is inserted into an outer knurling wheel  80 . The inner tube  70  has at least three inner tube collars  76 :—from right to left—a first inner tube collar  76  at the proximal end of the device  12 ; a second inner tube collar  76  at a distance from the first; a third inner tube collar  76  at a distance from the second inner tube collar  76 . The first inner tube collar  76  is a handle, the second inner tube collar  76  ensures that the inner tube  70  does not slip out of the outer tube  50  in an axial direction  15  towards the tip of the device  13 , the third inner tube collar  76  may secure the inner tube  70  against complete axial movement. For this purpose, the third inner tube collar  76  is guided in a groove of the outer tube. 
     Also, in the outer tube  50  at least a first outer tube collar  56  is manufactured, especially turned. This outer tube collar  56  also forms a handle. 
     In all embodiments, all handles may be knurled so that a treating person may hold them firmly. Furthermore, in all embodiments the outer diameter  51  of the outer tube of the handle of the outer tube  50  may be larger than the outer diameter of the inner tube  71  of the inner handle. Furthermore, in all embodiments, the outer diameter as well as the inner diameter may vary along the length of the device. 
     The inner diameter  72  of the inner tube is manufactured in such a way that a variety of tools may be passed through it. 
       FIG. 1 c    shows an inner part  90  of the device  10  in a schematic sectional view from the side. 
     The inner part  90  in the preferred embodiment comprises at least four components: a pin  100 , a probe  110 , a spring element  120  and a safety device  130 . 
     In the preferred embodiment, the pin  100  is manufactured tiered. The tip  105  of the pin, which points in the direction of the pericardium (not shown), is conical. From the tip  105  of the pin, the outer pin diameter  101  increases towards the knob  108  of the pin. At the outermost end of the tip  105  of the pin, the pin diameter  101  is thus the smallest. 
     A pin lock is countersunk into the pin tip  105 . Its pin hole diameter  107  is larger than the through hole diameter  103 . Pin  100  has a pin collar  104  at one end. 
     The probe  110  comprises a probe shaft  111  and a probe head  112 . 
     In the preferred embodiment, the inner part  90  is fitted in a first step by arranging the spring element  120  over the probe shaft  112 , and then in the second step by inserting the probe shaft with spring element  120  through the through hole of the pin  100 , so that finally in the third step the probe  110  may be secured against falling out or slipping out of the pin  100  by means of the safety device  130  (see  FIG. 1 d   ). 
       FIG. 1 d    shows a detailed view of a safety device. The safety device is located at the free end of the pin knob  108 . The free end of the pin knob  108  is ventral in a preferred position for use. In an alternative use position it is lateral. Both positions of the free end of the pin knob  108  mark its position according to the main anatomical directions away from the body. The safety device  130  prevents the probe from slipping out of the pin in the dorsal direction, in which a retaining ring  132  fits, preferably press fits, into a retaining groove  131 . 
     In an alternative embodiment, a locking cotter pin (not shown) may also be inserted into a locking bore (not shown), which is drilled transversely to the core of the pin, with positive or frictional locking, e.g. plugged, inserted and bent, fitted, in particular press fitted. 
       FIG. 1 e    shows a view along the section E 0 -E 0  from  FIG. 1 a   . In the section the size relations of the handles discussed above become clear. 
       FIG. 2  shows different views of an outer part end of the device. The outer part end describes a dorsal section of the outer part. 
       FIG. 2 a    shows a detailed view of an outer part end  41  in a schematic sectional view from the side. 
     In the preferred embodiment, its outer part end length  42  is approx. 2 cm long, in further configuration it is 1 cm. In alternative embodiments it is designed according to the elasticity of the pericardium (not shown) or other inner skins (not shown), body layers (not shown), organs or the outer skin. At the dorsal tip of the inner part end there is a volume  16  between the outer tube  50  and the inner tube  70 . 
     In the preferred embodiment, volume  16  is the result of an outer part end shoulder  43 . The outer part end shoulder is made out of the outer tube  50  and is manufactured along the inner circumference of the outer part end  41 , especially turned or milled. 
     In an alternative embodiment, a shoulder (not shown) may also be made in the inner tube  70  or shoulders may be made in the outer tube  50  and inner tube  70 . 
     In further configuration of both preferred or alternative embodiments, the shoulders may have different profiles, for example ribbed, rising, curved, jagged or tapered profiles (not shown). Also, a plurality of outer part end shoulders  43  may be made along the inner circumference of the outer part end  41  into the outer tube  50  or the inner tube  70 . In particular, the inner tube ends  74 , outer part end surface  44  and outer tube end surface  54  may be profiled individually or in combination. Different profiles increase the friction forces along the surfaces and ends. 
       FIG. 2 b    shows a detail view of an outer part end as a sectional view from right to left. The detail view shows that the outer part end surface  44  is formed from an outer tube end surface  54  and an inner tube end surface  74 . 
     In a preferred embodiment, this describes a total area. The outer part end surface  44  lies in the dorsal direction, i.e. its surface vector (not shown) points in the direction of the human body (not shown) according to the main anatomical directions, and the same applies to the surface vectors (not shown) of its partial surfaces. 
     In a further embodiment, both the outer partial end surface  44 , i.e. an end face, and its partial surfaces or sections may be profiled. Preferably the profile is manufactured in such a way that a high degree of roughness is achieved. As an example, a high roughness is given if the profile has a roughness value defined in the engineering sciences, wherein the high or low value of the roughness value defines the profile as rough. As one roughness value—among many others—the so-called RA value may be used. 
     In further embodiment, using the example of the RA values, roughness of the outer tube end face  54  and the inner tube end face  74  differ. 
     In the use position, a direction of rotation of the outer knurling wheel  61  is opposite to the direction of rotation of the inner knurling wheel  81 . 
     In contrast to  FIG. 2 b   ,  FIG. 2 c    shows a detail view of an outer part end as a sectional view from left to right. 
     An outer tube end surface profile is machined into the outer tube end surface  54 , in particular a profile that includes outer tube end surface notches  59   a  and inner tube end surface notches  79 . In the preferred embodiment, the outer tube end surface notches  59   a  are machined into the outer tube end surface  54  at equal distances (not shown) from each other radially. The inner tube end surface notches are also manufactured radially as inner tube end surface profile  78  into the inner tube end surface at equal distance (not shown) from each other. The main direction of the outer tube end surface notches  59   a  are substantially opposite, oblique, to the main direction of the inner tube end surface notches  79 . 
     In further detail, the outer tube end surface profile and the inner tube end surface profile  78  differ. The difference is characterized in that at least one first main direction (not shown) of the outer tube surface face profile is opposite to at least one second main direction of the inner tube end surface profile  78 . 
     Alternatively, in further embodiments, the first and second main directions may be substantially opposite. When the first and second principal directions are vectorially interpreted; and when a first sub-vector of the first principal direction vector and a second sub-vector of the second principal direction vector are parallel but opposite, it may be indicated that the first principal direction and the second principal direction are substantially opposite. 
     In a more detailed configuration, the first and second principal directions may be arbitrarily positioned relative to each other. 
     If the direction of rotation of the outer knurling wheel  61  is opposite to the direction of rotation of the inner knurling wheel  81 , the profiles hook into each other. 
       FIG. 3  shows a preferred embodiment of the device. 
     It is called a “serrated gripper”. The “serrated gripper” illustrates the phenomenon of mechanical pericardial lifting from the heart by gripping behind the pericardium with tines. This back-gripping may also be called back-prong gripping. Alternative names for the “serrated gripper” are “back-jaw gripper” or “scaled gripper”. 
     A tine usually describes at least one point, hook, barb, slat or scale at the edge. It is usually attached to this edge, an end, at one of its serrated ends. At at least one other end of the tines is sharp-edged, in particular ground and filed. A serrated gripper may also be considered a tooth, for example a saw blade tooth.  FIG. 3 a    shows a schematic view of the first alternative embodiment. It shows a “serrated gripper” as an “outer part serrated gripper”. 
     In a preferred embodiment, the tines  220  are located at the tip of the fixture  13  on the outer part  40 , in a further embodiment they are located in the area of the outer part end or in the area of the inner part tip, preferably in the area of the pin tip. In the case that the tines  220  are arranged in the area of the outer part end, an arrangement of at least one tine  220  either in the area of the outer tube end and/or in the area of the inner tube end of the preferred embodiment is also possible. 
     In the preferred embodiment, tines  220  are provided at the outer tube end  53  for this purpose. In a further embodiment these may be manufactured in one piece with the outer tube  50 . In the preferred embodiment, the tines  220  are injection moulded in one shot with the outer tube  50 . Alternatively, they may be welded or soldered as individual lamellae to the outer tube end  53 . 
       FIG. 3 b    shows a schematic view of the first alternative embodiment, with a pin  100  for “jagged gripping”. 
     In the preferred embodiment, the tines  220  are cast in a serrated pocket  222 , in the alternative embodiment they are cast on the outer surface of the pin  100 , in one piece with the pin  100 , preferably at the pin tip  105  in the injection moulding process. 
     In the preferred embodiment, all tines  220  have the same setting angle  223  to the pin  100 , e.g. serration centerline  221  to the pin axis. 
       FIG. 3 c    shows a schematic view of the first alternative embodiment from the front. Tines  220  in a scaled form are glued or welded to the tip of the pin as scales. The length of tines  220  (not shown) varies. Therefore, the tines  220  overlap in parts. In the direction of the tips of the tines, in clockwise direction, the tines  220  rotate or swivel in gripping direction  225 , whereas they run counter-clockwise in freewheel  224 . Swiveling of the serrated gripper involves small, i.e. gradual rotation of the serrated gripper about its axis. Swiveling may take place both in gripping direction  225  and in freewheel direction  224 .  FIG. 4  shows a schematic view of another alternative embodiment. 
     This embodiment may be described as “groove gripper”  230 . 
     The “groove gripper” illustrates the phenomenon of a mechanical pericardial stroke by allowing pericardium to flow, be pulled or pressed into a groove made in it so that it may be clamped there. 
       FIG. 4 a    shows an initial further development of the groove gripper  230 . 
     The first preferred embodiment, the “outer tube slot gripper” is characterized by the fact that at least one slot  231 . 1  is made in the outer tube  50 . 
     In the second preferred embodiment, the “inner tube slot gripper” is characterised in that at least one slot  231 . 2  is made in the inner tube  70 , in particular in the region of the device tip. 
     In the third preferred embodiment, the “inner part groove gripper” is characterised in that at least one groove  231 . 3  is made in the inner part  90 , preferably in the pin  100 , in particular in the region of the pin tip. 
     The preferred manufacturing process for the insertion of at least one groove into one of the proposed further developments of the groove gripper is injection moulding. The groove is therefore incorporated, e.g. milled, during the production of the respective further configuration. Alternatively, the groove may be manufactured or reworked in a later work step after completion of the further configuration. Preferably it is milled out for this purpose. 
     In use, a second type of further configuration is pressed into a tissue section or a tissue subsection, such as the pericardium, until the tissue flows into or behind the groove and is pressed. By swiveling, rotating or partially rotating, in particular turning the groove gripper, the pericardium is then twisted, i.e. swirled, such that the pericardium is frictionally and/or positively mounted in the groove, i.e. fixed, clamped, in the sense of gripped. 
       FIG. 5  shows a schematic flow chart of a method. 
     The preferred sequence is shown in  FIG. 5  by steps. They are referred to with “S”. Thick arrows indicate main steps, thin arrows indicate alternative intermediate steps. Thick ones, like thin ones, run according to plan, but thin ones usually run in loops so as not to overtake thick ones. In contrast to steps, states are represented as boxes. They are marked with “Z”&gt;. 
     In the preferred embodiment in the use position, the surface vectors (not shown) of both the outer tube end surface and the inner tube end surface point in the direction of the pericardium. 
     In a preferred embodiment step S 0 , a human body (not shown) is opened. This is done by cutting it open with a scalpel to create a body access opening. The extent of this opening may vary between at least two extreme positions: a minimum possible body access opening, e.g. a puncture, and a maximum possible body access opening, e.g. an open thorax. 
     Preferably, a treating person will create a subxiphoidal body access. Alternatively, an access may be opened intercostal or apically. The terms mentioned above subxiphoidal, intercostal and apical describe main anatomical directions. 
     After a body access has been created, it may be used to insert a device, in particular a device according to the disclosure, a ring, serrated or groove gripper (not shown) into the patient (not shown). 
     In an alternative intermediate step S 1   b , the body access opening may be secured by the treating person using a suitable tool (not shown). 
     The device is then used to penetrate the human body in step S 1   a , in which a treating person advances it. The advancement is characterized by probing, a careful exploration as well as by dilating, creating a space. 
     In at least one intermediate step S 1   c , surrounding human tissue (not shown), organs (not shown) or skins (not shown) are displaced or severed in parallel if necessary in order to drive the device further through the human body (not shown). In an alternative intermediate step S 1   d , the treating person may check which human tissue (not shown) he or she is displacing or severing. The person may also check whether he or she still drives the device towards the pericardium. 
     As soon as the device touches the pericardium with one of its device ends, the latter generates a signal. In a preferred embodiment, the signal is haptic, i.e. the signal is felt by the treating person. The touch is experienced by noticeably increasing resistance. In a second preferred embodiment, the signal is generated by an electrical signal generator, which may alternatively generate signals acoustically or optically. The signals are recorded by the signal generator so that treatment may be followed. 
     When condition Z 2  is reached, intermediate steps may be initiated by the treating person. 
     Preferred intermediate steps serve to take a situation picture. An x-ray or ultrasound image or an electrocardiogram (ECG) or a combination of these shall be recorded. 
     Next, the treating person slides the outer part over the inner part until the tip of the inner part touches the pericardium. If this condition is “Z 3 ”, the device is in working position. 
     If the device is in working position and is a “ring gripper”, the pericardium is gripped by twisting the ring gripper. The pericardium is gripped by rotating or partially rotating the outer tube and the inner tube. The rotation or partial rotation of the aforementioned tubes is preferably done in the opposite direction. In a more detailed embodiment, the direction of rotation of the inner knurling wheel is thus opposed to the direction of rotation of the outer knurling wheel. 
     When the device is in the working position and is configured as a serrated gripper, the pericardium (not shown) is gripped by hooking the pericardium (not shown). The tines (not shown) on the serrated gripper are pressed into the pericardium, preferably slightly depressed, and the serrated gripper is slightly rotated or oscillated so that the pericardium (not shown) or sections of pericardium (not shown) flow behind the tines (not shown), are pressed, pushed or conveyed and become hooked there. 
     When the device is in working position and configured as a groove gripper, the pericardium is gripped by twisting it. The groove gripper is slightly pressed into the pericardium and/or rotated or oscillated so that the pericardium or its pericardial sections (not shown) flow into the groove, are pressed or conveyed. By increasingly rotating the groove gripper, the pericardium is conveyed further into the groove by being pulled into it. The increase in pericardium compresses it in the groove, resulting in an increase in its frictional and positive locking. 
     If the treating person has grasped the pericardium in procedure step S 3  and is convinced of the grip, then the condition “Z 4 ”, the pericardial grip mentioned here, is present. 
     In further embodiment of the procedure, the inner part may now be removed from the outer part, procedure step S 4 , so that access to the pericardium as a tunnel, passage, hose or tube through the device , at least one device tunnel, is opened. 
     A punch tube (not shown) may be inserted through the access in order to punch a puncture into the pericardium. In preferred embodiment, the punch tube is a cannula. 
     In a further embodiment of the procedure, the treating person may insert an implant into the pericardium through the device tunnel. Preferably the implant is a drainage, a probe or a cushion. 
     Alternatively, and/or consecutively, the implant may be guided into or out of the pericardium by an implant guide. 
       FIG. 6  shows a schematic diagram of the positions of the device in use. 
       FIG. 6 a    shows a position of the device  10  . The device  10  is configured as a ring gripper  20  and inserted into the human body  200  through the body access opening  201 . The tip of the device shows a penetration depth  202 , i.e. its distance to the body access opening  201 . The working depth  203  describes the distance between the pericardium  34  and the body access opening  201 . The ring gripper  20  is in working position “Z 4 ” when the tip of the device lies against the pericardium  34 , i.e. when it touches it. 
       FIG. 6 b    shows a position of the device  10  in the form of ring gripper  20  in pericardial contact, “Z 2 ”. 
     In the working position, the probe head  112  presses against the pericardium  34 . The probe pulsates because the pericardium  34  pulsates due to the beating of the heart (not shown), the movement follows consecutively from the strength of the pericardial pulsation and the strength of the spring element  120 . 
     In the preferred embodiment, spring element  120  is a spiral or disc spring, a piece of foam or a piece of rubber. 
       FIG. 6 c    shows a working position “Z 3 ” of the device  10  in the form of ring gripper  20 . 
     The outer part  40  touches the pericardium  34  with its outer part end  41 , while the inner part  90  is spaced apart from the pericardium  34 . 
       FIG. 6 d    shows a device  10  with gripped pericardium, pericardial grip “Z 4 ”. 
       FIG. 6 e    shows an alternative embodiment of a device with a serrated gripper  220   a  in an insertion position. The serrated gripper  220   a  is guided by an inner tube  70  and an outer tube  50  at its serrated gripping shaft  220   b.    
       FIG. 6 f    shows another preferred variant. The serrated gripper  220   a  is only guided by a support structure  290 . This may be an inner tube (not shown), a hose (not shown) or a so-called soft tissue retractor  291 . If the support structure  290  is a soft tissue retractor  291 , it may be positioned on at least one section of pericardium  34 . In preferred advanced configuration, the soft tissue retractor  291  has a funnel at its apical end. The serrated gripper  220   a  may be advanced through it until it touches the pericardium  34 . By slightly swiveling the pericardium  34 , a blind hole is cut into it by the tines  220  (see  FIG. 3 ), into which the serrated gripper  220  may be plugged in. If this grips the pericardium  34 , a puncture needle  250  may be advanced to open the pericardium  34 . In  FIG. 6 f   , the serrated gripper  220   a  is in a gripping position, i.e. the serrated gripper  220   a  and the pericardium  34  form at least one temporary hold. In the preferred embodiment, this results from the flowing of pericardium  34  or pericardium parts (see  FIG. 3 c   ) around the tines (see  FIG. 3 c   ) or from mechanical penetration of the tines  220  into the pericardium  34 . 
       FIG. 6 g    shows another preferred embodiment. This has at least one locking shoulder  294 . In use, the serrated gripper  220   a  is advanced through a support structure  290  and pericardium  34  is gripped by tines (not shown, see  FIG. 3 ). The gripped pericardium  34  is taken along and pulled behind the locking shoulder  294  to clamp it. Phenomenologically, the tines (not shown) thus form drivers. Once the pericardium  34  is clamped, a puncture needle  250  is advanced to open the pericardium  34 . The support structure  290  is made of an elastic material so that it may bend open when the pericardium  34  is pulled behind the locking shoulder  294  by the serrated gripper  220   a.    
     Regardless of the type of embodiment, the serrated gripper has circumferential tines (see  FIG. 3 ) at its apical end, i.e. at least two tines are arranged along the circumference of the serrated gripper. These are milled from solid titanium or aluminium. Preferably, the serrated gripper is made in one piece for this purpose. Alternatively, the serrated gripper may also be made in two pieces. The apical end is punched from a blank, resulting in a circular saw blade or a cutter (see  FIG. 3 c   ). This is alternatively glued, clamped, pressed or welded to at least one section of the serrated gripper shaft. 
     In a preferred embodiment, the serrated gripper runs freely against the shape of the tines. This direction forms the so-called freewheel. In the opposite direction, i.e. clockwise,  FIG. 3 c    shows the serrated gripper running in the gripping direction. During the movement in the circumferential direction, the gripping tool, which is provided with tines on the circumference, may dig into the wall of the blind hole of the pericardium with the tines and slide along the wall of the pericardium in the other circumferential direction. 
       FIG. 7  shows a device  10  in a position of use with sealings  280 . Those sealings seal the open pericardium  34  against the device  10  so that free fluid flow, e.g. a gas flow (not shown) into or out of the pericardium  34  is prevented. 
     The aforementioned embodiment may also be used independently of other embodiments. 
     The pericardium  34  is under pressure within its physiological limits (not shown). This pressure, the internal pressure of the pericardium  36 , is reduced compared to the ambient pressure (not shown) in the interval of approx. −15 mmHG to 0 mmHG. Within physiological parameters, the internal pericardial pressure  36  is therefore a negative pressure. The negative pressure fills an internal volume  39  between the heart  31  and the inner side of the pericardium  35 . 
     The problem is that opening the pericardium  34  may result in a serious loss of pumping capacity of the heart  31 . 
     If the pericardium  34  is opened without sealing, the ambient pressure and the internal pressure  36  of the pericardial sac equalize, the pericardium  34  loses its internal compression, so that the heart  31  is no longer held in a functionally supportive form. The plane of the heart valves (not shown) and the tip of the heart are connected by tissue. As long as the tip of the heart  32  is sucked into the pericardium  34  by the negative internal pressure of the pericardium  36 , i.e. a negative pressure, the pericardium  34  keeps the heart  31  in its typical contour. Because the apex  32  is held, the plane of the heart valves moves in relation to the apex. Without negative pressure, however, the apex  32  is loosely supported in the pericardium  34 , so that it moves in relation to the plane of the heart valves. This reduces the functionality of the heart valves (not shown), including their stroke, which results in a decrease of the pumping capacity of the heart  31 . The loss of power assistance corresponds to a loss of pumping power of the heart  31  of more than 20%. 
     The problem is solved by keeping the internal pressure of the pericardium  36  under pressure before, during and after treatment, i.e. below ambient pressure. Phenomenologically, the device  10  is therefore sealed against an increase in the internal pressure of the pericardium  36  to the ambient pressure. It is monitored and controlled by at least one vacuum pump  260 . In the position of use, the embodiment variant in  FIG. 8  comprises an inner tube  70  through which a support structure  290  is passed. 
     In a preferred embodiment, the support structure  290  is a so-called soft-tissue retractor  291 , which acts advantageously as a moisture barrier and seals against fluid loss. 
     An inner part  90  is movably guided by the support structure  290 . Its degree of freedom may be predetermined by different tolerances in different embodiments. In the case of a standard tight embodiment, the inner part  90  is fitted against the support structure  290  at the transition, so that both friction partners seal against each other due to minimal friction. Sliding gel is used as an insertion aid, which is applied to the inner part  90  before it is guided through the soft-tissue retractor  291 . 
     The inner part  90  is manufactured with steps, preferably inner part collars  93  are extracted of the solid material, e.g: titanium, aluminum or steel alloys, e.g. milled or turned and inserted through the skin  37 . The inner section collars  93 , (steps) vary in their inner section diameter  94 , they increase from top to bottom in  FIG. 8 , i.e. in the apical direction. In a preferred embodiment, a first inner section collar diameter  94  (step diameter) is smaller than a second, apically twisted inner section collar diameter  94 . An elastic body, a sealing  280  is mounted on the second inner section collar diameter  94 . In advantageous configuration the sealing  280  is a stuffing box  281 , which is made of an elastomer such as rubber or silicone, for example, and is pushed with clearance onto the second inner part collar diameter  94 . An additional spacer  272  is guided over the second inner part collar  93 . This spacer is loosely mounted axially along the length of the inner part. At its apical end, the apical spacer end  273 , it touches the stuffing box  280  in the position of use shown. The actuating force of a mechanical mechanism  270 , in a preferred embodiment the tightening force of a nut  271 , is transmitted to the spacer  272  because the spacer  272  is loosely mounted, so that the stuffing box  281  is compressed and deforms according to its elastic behaviour. Its expansion will decrease axially and increase radially until it first contacts and then presses against the inside of the soft tissue retractor  291 . The introduction of a tightening force thus results in a sealing between the inner part  90  and the soft tissue retractor  291  by pressing in a shaped body. 
     A vacuum pump  260  is attached by a flange  261  at the ventral end of the inner part  90 , i.e. in  FIG. 7  at the upper end of the picture. In a preferred embodiment, this pump maintains a pressure below ambient pressure before, during and after the insertion of the device  10 . Advantageously, a control of the negative pressure may be used to support heart contraction. This support may include, in a preferred configuration, either static or dynamic pressure changes or both of the above-mentioned pressure changes. 
     The object is also solved by providing an airlock (not shown). For this purpose, an airlock chamber (not shown) may be placed on the inner part  90  or flanged on as soon as pericardium  34  is open. 
     As soon as the inner part  90  has been hooked to the pericardium, an opening tool, e.g. a serrated gripper (not shown) may be inserted into the inner part  90  as soon as all chambers (not shown) of the airlock have been brought to the same negative pressure. 
     After reaching this negative pressure a slide (not shown) between at least two chambers (not shown) may be opened and a used tool may be pulled out of the chamber into the lock chamber. Then the slide valve between the two chambers is brought back into the closed position. Afterwards the lock chamber may be opened and the used tool may be exchanged for another one. After closing the lock chamber, the vacuum is generated again in the airlock chamber so that the slide (not shown) may be opened again and the new tool or the implant (not shown) may be brought into position through the construction. It is advantageous that a tool change may be repeated as often as required. 
     The opening tool will then be actuated from outside the airlock in a preferred embodiment. For this purpose, small hydraulically actuated lifting cylinders and cylinders for a rotary movement are available in the technology, which may also be accommodated in the tubes. Alternatively, these hydraulic cylinders may be integrated into the pipe construction. After a pericardial opening  34   a , e.g. in view of a treatment, the problem arises to close the pericardial opening  34  again. This object is solved by the device  10  , in that the vacuum pump  260  creates a vacuum in the pericardium  34 , which is suitable for creating a certain negative pressure there, so that the heart  31  is pulled into a physiological shape. By drawing the negative pressure, the device thus consecutively solves the object of restoring a functionality of the heart valve plane before the pericardium  34  is closed. In a preferred embodiment, the pericardial opening  34   a  is closed by laser, suturing, gluing or stapling. 
       FIG. 8  shows a detailed view of a device in two different states: closed and open or sealed and gas permeable, respectively. 
       FIG. 8 a    shows a detailed view of a device  10  in a gas permeable position of use. The moulded body, the stuffing box  280  is free of compression forces, so that at least one gap  301  results. 
       FIG. 8 b    shows a detailed view of a device  10  in a gas-tight position for use. The sealing  280 , i.e. the stuffing box  281 , rests on the soft tissue retractor  291 , a support structure  290 , so that a free gas flow (not shown) is prevented by gaps (cf.  FIG. 8 a   ); the inner part  90  is sealed against the soft tissue retractor  291 . For sealing, the spacer  272  presses the stuffing box  281  together. 
       FIG. 9  shows a detailed view of a device in two different states: gas permeable and gas tight. 
       FIG. 9 a    shows a detailed view of a device  10  in a gas permeable position of use. The pericardium  34  is severed, resulting in a gas flow  300  into or out of the pericardium  34 .  FIG. 9 a    shows three gas flows  300 , one flowing in a first path through at least one first inner part bore into the pericardium  34 , in a second path between at least one outer surface of the inner part  90  and a support structure  290 , a tube  70  or  50 , in a third path between the outer surface of the inner part  90  and at least one open end, i.e. a cone  70   a .  FIG. 9 b    shows a detailed view of a device  10  in a gas-tight position of use. The pericardium  34  is clamped between the support structure  290 , between a soft tissue retractor and a cone  70   a  and is thus sealed. 
       FIG. 10  shows a schematic diagram of positions of a device for the insertion of an implant (not shown). 
     The aforementioned embodiment may also be used independently of other embodiments. 
       FIG. 10 a    schematically shows an opening position at a treatment site. A skin section  37  or skin  37  is severed so that an insertion opening  37   a  is opened. It is placed e.g. by a scalpel incision. A soft tissue retractor  291  may then be advanced through the insertion opening  37   a.    
     In a preferred method, its feed stops as soon as it rests on the pericardium  34 . The contact may be felt, palpated or optically checked manually or mechanically. When the soft tissue retractor  291  is in contact, a cutting or pushing instrument may be guided through it and advanced until the pericardium  34  is reached and severed. Alternatively, the pericardium  34  may be opened with at least one cannula (not shown), special tools (not shown), e.g. ring, groove or serrated gripper, a needle (not shown) or a scalpel (not shown). One end of the soft tissue retractor  291  is advanced through the opened pericardium  34  until its apical clamping ring  292  is clamped behind the pericardial opening. 
       FIG. 10 b    schematically shows an opened treatment site with an inserted soft tissue retractor  291 . An apical tension ring  292 , an anterior tension ring  293  or both of the soft tissue retractor  291  are folded, compressed, crumpled manually or mechanically until he or she may be passed through at least one outer part  40  or an inner tube (not shown) or an outer tube (not shown) or a plug connection of inner and outer tube (see  FIG. 6 e   ). In the preferred embodiment, the outdoor part is a so-called sleeve tension funnel. If the soft tissue retractor  291  is guided through a sleeve tension funnel, the sleeve tension funnel is advanced towards the pericardium until it touches the entrance of the funnel, i.e. a cone  70   a .  FIG. 10 c    shows a clamping of a soft tissue retractor  291  to clamp pericardium  34  between an inner side of a cone  70   a  and an apical clamping ring  292  of a soft tissue retractor  291 . For this purpose, the upper end of the soft tissue retractor  291  is pulled at the ventral clamping ring  293 , in the picture the upper end of the soft tissue retractor  291 . At least parts or sections of the apical clamping ring  292  take pericardium  34  with them until it clamps in cone  70   a.    
       FIG. 10 d    shows a sealed pericardial opening  34   a . Between a soft tissue retractor  291  and a cone  70   a , pericardium  34  is clamped, preventing fluid flows, especially gas flows (not shown), that gaps are closed (not shown). 
       FIG. 11  shows a schematic diagram of the positions of an implant. 
       FIG. 11 a    shows a layer of an implant  150  within the device  10 . The implant  150  is connected to an implant guide  154 . In the preferred embodiment, an implant guide is provided between implant  150  and implant guide  154  as a fracture site  155 . Alternatively, this may be broken by wobbling or turning it more strongly so that implant  150  is separated from implant guide  154 . 
     In a preferred embodiment, a passage through the implant  150 , the fracture site  155  and the implant guide  154  has been worked out. Compressed air or fluid may be introduced into or removed from the implant  150  through this passage. 
     In a preferred embodiment, a guide wire  240  is passed through the continuous passage, which is connected to the implant  150  in at least one location. The connection point may be a knot, a welding point or an adhesive point. Because the guide wire  240  is attached to the implant  150 , the implant may be guided through the guide wire  240 . 
     In a preferred embodiment, the implant  150  is a cushion  153 , whose volume may be changed over time by adding and removing compressed air. Alternatively, a gas may be used. 
     Alternatively, a guide wire  240  may be inserted through the device tunnel  19 , which is attached to the outside of implant  150 . 
     By means of the guide wire  240 , the implant  150  may be advanced in the direction of the heart  31  up to the pericardium  34   
       FIG. 11 b    shows a position of an implant  150  within the device or any other tubular guide structure. The implant  150  is alternatively advanced through the device tunnel  19  in the direction of the pericardium  34  by a guide wire (see  FIG. 11 a   ) or by an implant guide (not shown). 
       FIG. 11 c    shows an alternative position of an implant  150  compared to  FIG. 11 b    for its temporary support. For this purpose, the pericardium  34  is opened so that implant  150  may be advanced through a pericardial opening. 
     The object is to insert the implant  150  as deeply as possible into the pericardium  34 . This object is solved by a method in which an implant anchor  310  is inserted and fixed in the pericardium  34 . 
     The method comprises the steps of opening skin (not shown), advancing a device through the opening to the pericardium  34 , grasping and opening the pericardium  34 , advancing an implant anchor  310  through the device and through the pericardial opening  34   a  and placing it between an inner side of the pericardium  34 , between the pericardium  34  and the heart  31 , returning at least one guide wire  320  and passing it through a passage of an implant  150 , and advancing the implant  150  along the guide wire  320  through a device tunnel  19  of guide wire  320  to implant anchor  310 . 
     It is advantageous to position at least one implant  150  securely between the heart  31  and pericardium  34  so that an implant  150  may be placed at a predefined location. 
     In a preferred embodiment, a fluid column is used as the diaphragmatic seal of implant  150 . This solves the object of transmitting pressure changes almost immediately. If the heartbeat is measured in the implant at the same time, the support of the heart may be optimally controlled by a computer-aided control system. 
     The embodiment shown in  FIG. 11 c    may also be used independently of other embodiments. 
       FIG. 11 d    shows a detailed view with an implant anchor  310 . 
     Implant anchor  310  is sutured to the pericardium  34  with at least one cord  311  and at least one eyelet  312 . In a particularly advantageous embodiment, the implant anchor  310  is sutured to the pericardium  34  on its circumference by means of a plurality of eyelets  312 . A guide wire  320  is attached to it. 
       FIG. 11 e    shows a detail with an implant anchor  310 , which is sucked to the pericardium  34  by means of negative pressure. For doing that, a guide suction hose  321  is flanged to the implant anchor  310  so that air or fluid from at least one implant dome  313  in the implant anchor  310  may be conveyed, e.g. pumped. This has the advantage that the implant anchor  310  is sucked up to the pericardium  34 . A guide wire  320  or a guide cable (not shown) or a guide cord (not shown) may be additionally attached to the implant anchor  310 . 
     LIST OF REFERENCE NUMBERS 
       10  Device 
       12  proximal device end 
       13  Fixture tip 
       15  Axial direction 
       16  Volume 
       19  Device tunnel 
       20  ring grippers 
       31  Heart 
       32  Tip of the heart 
       33  Heart 
       34  Pericardium 
       34   a  Pericardial opening 
       35  Inner pericardium 
       36  Internal pressure of pericardial bag 
       37  Skin 
       37   a  Insertion opening 
       39  Interior volume 
       40  Outer part 
       41  Outer part component end 
       42  Outer part end length 
       43  Outer part end section 
       44  Outer part end surface 
       50  Outer tube 
       51  Outer diameter of the outer tube 
       52  Inner diameter of the outer tube 
       53  Outer tube end 
       54  Outer tube end surface 
       56  Outer tube collar 
       59  Outer tube end surface profile 
       59   a  Outer tube end surface notches 
       60  Outer knurling wheel 
       61  Rotation direction outer knurl wheel 
       70  Inner tube 
       70   a  Cone 
       71  Outer diameter of the inner tube 
       72  Inner diameter of the inner tube 
       74  Inner tube end surface 
       76  Inner tube collar 
       78  Inner tube end surface profile 
       80  Inner knurling wheel 
       81  Direction of rotation inner knurling wheel 
       90  Inner part 
       93  Inner part collar 
       94  Inner part collar diameter 
       100  Pin 
       101  Outer pin diameter 
       102  Through-hole 
       103  Through-hole diameter 
       104  Pin collar 
       105  pin tip 
       106  Pin hole 
       107  Pin hole diameter 
       108  Pin knob 
       109  Pin length 
       110  Probes 
       111  Probe shaft 
       112  Probe head 
       120  Spring element 
       130  Safety device 
       131  Safety groove 
       132  retaining ring 
       150  Implant 
       153  Pillow 
       154  Implant guide 
       155  Implant guide fracture site 
       200  Human body 
       201  Body access opening 
       202  penetration depth 
       203  Working depth 
       220  tine 
       220   a  Serrated gripper 
       220   b  serrated gripper shank 
       221  Serrated centre line 
       222  Tine pocket 
       223  Angle of attack 
       224  Freewheel 
       225  Gripping direction 
       230  Groove gripper 
       231 . 1  Outer tube groove 
       231 . 2  Inner tube groove 
       233 . 3  Internal part groove gripper 
       240  Guide wire 
       250  Puncture needle 
       260  Vacuum pump 
       261  Flange 
       270  Mechanical mechanism 
       271  Nut 
       272  Spacers 
       273  Apical spacer end 
       280  sealing 
       281  stuffing box 
       290  Support structure 
       291  soft tissue retractor 
       292  Apical clamping ring 
       293  Ventral clamping ring 
       294  locking shoulder 
       300  Gas flow 
       301  Slit 
       310  Implant anchor 
       311  Cord 
       312  eyelet 
       313  implant dome 
       320  Guide wire 
       321  Guide suction hose