Patent Publication Number: US-11660085-B2

Title: Device for cardiac surgery and methods thereof

Description:
RELATED APPLICATIONS 
     This application is a continuation of and claims priority to U.S. 371 application Ser. No. 15/750,215 filed Feb. 5, 2018 and entitled “DEVICE FOR CARDIAC SURGERY AND METHODS THEREOF”. The 371 application Ser. No. 15/750,215 claims priority to international PCT Application PCT/US2017/037203 filed Jun. 13, 2017 and entitled “DEVICE FOR CARDIAC SURGERY AND METHODS THEREOF”. The International PCT application PCT/US2017/037203 claims priority to U.S. provisional patent application No. 62/349,414 filed Jun. 13, 2016 and entitled, “DEVICE FOR CARDIAC SURGERY AND METHODS THEREOF”. The PCT/US2017/037203 application also claims priority to U.S. provisional patent application No. 62/350,949 filed Jun. 16, 2016 and entitled, “DEVICE FOR CARDIAC SURGERY AND METHODS THEREOF”. The Ser. No. 15/750,215, PCT/US2017/037203, 62/349,414 and the 62/350,949 applications are hereby incorporated by reference in their entirety. 
    
    
     FIELD 
     The claimed invention relates to surgical devices, and more specifically to a device for cardiac surgery and methods thereof. 
     BACKGROUND 
     In many types of minimally invasive cardiac surgery, it is often desirable to access the aortic valve and/or left ventricle of the heart through a portion of the aorta. In order to create an aortotomy (incision through the aorta), it is first necessary to securely clamp and/or occlude the aorta away from the heart, place the patient on bypass perfusion, and temporarily stop the heart from beating, for example, with cardioplegia. This depressurizes the aorta and can cause the walls of the aorta to flop down after an incision is made in the aorta, thereby blocking the surgeon&#39;s view of the aortic valve through the incision. Furthermore, even when the flaps of the aorta around the incision are held out of the way, it can still be difficult to see the aortic root where the flaps of the aortic valve are attached to the heart. Therefore, it would be helpful if there were a device for cardiac surgery which could help to increase a surgeon&#39;s visualization of the aortic root in such a minimally invasive surgical procedure. 
     SUMMARY 
     A device for cardiac surgery is disclosed. The device has a frame and a plurality of suture guides spaced about the frame. 
     A further device for cardiac surgery is disclosed. The device has a plurality of pairs of suture guides spaced about the frame. The device also has a plurality of suture tubes, with one suture tube corresponding to each pair of suture guides. The device further has a plurality of snares, each corresponding to and passed through one of the plurality of suture tubes so that a handle at one end of the snare protrudes from a proximal end of the corresponding suture tube and a snare loop at another end of the snare protrudes through a distal end of the corresponding suture tube, and wherein the snare loop further protrudes through one of the suture guides in the corresponding pair of suture guides. The device also has a plurality of sutures, each corresponding to one of the pairs of suture guides and coupled to the suture guide in the corresponding pair of suture guides which does not have the snare loop passing through it. 
     Another device for cardiac surgery is disclosed. The device has a frame and a plurality of suture guides spaced about the frame. The device also has a plurality of legs extending downward from the frame, each leg coupled to a foot. The device further has a plurality of sinus supports coupled to the frame. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG.  1    is a perspective view of one embodiment of a device for cardiac surgery. 
         FIG.  2    is an exploded view of the device for cardiac surgery from  FIG.  1   . 
         FIGS.  3  and  4    are top views of the device for cardiac surgery from  FIG.  1   , the views illustrating the device in an opened and a closed position, respectively. 
         FIGS.  5 A- 5 D  illustrate one embodiment of a surgical setting and a surgical method where the device for cardiac surgery from  FIG.  1    finds utility. 
         FIG.  6    is a top view of another embodiment of a device for cardiac surgery, this embodiment being one fixed piece and having the suture guides in each pair of suture guides spaced more closely together than the embodiment of  FIG.  1   . 
         FIG.  7    is a top view of a further embodiment of a device for cardiac surgery, this embodiment being hinged in a different manner as compared to the embodiment of  FIG.  1   . 
         FIG.  8    is a top view of a portion of a frame on another embodiment of a device for cardiac surgery, this embodiment having a different arrangement of suture guides as compared to previous embodiments. 
         FIG.  9    is a schematic view of a further embodiment of a device for cardiac surgery. 
         FIG.  10    is a perspective view of another embodiment of a device for cardiac surgery, this embodiment having suture guides located on frame tabs which are bent out of a plane which the remainder of the frame occupies. 
         FIG.  11    is a perspective view of a further embodiment of a device for cardiac surgery, this embodiment having a skirt coupled to the frame. 
         FIGS.  12  and  13    are top views of another embodiment of a device for cardiac surgery, shown in closed and open positions, respectively, and having substantially equal suture guide spacing in the closed position. 
         FIGS.  14 A and  14 B  are top views of a further embodiment of a device for cardiac surgery, the views illustrating the device in a closed and an opened position, respectively. 
         FIGS.  15  and  16    are perspective and top views, respectively, of another embodiment of a device for cardiac surgery. 
         FIGS.  17 A,  17 B,  17 C,  17 D,  17 E, and  17 F  are top, left, right, bottom, rear, and front elevational views, respectively, of the device for cardiac surgery from  FIG.  15   . 
         FIG.  18    is a side view of one of the tabs protruding from the frame of the device for cardiac surgery from  FIG.  15   . 
         FIGS.  19 A and  19 B  are bottom and top perspective views, respectively of one of the tabs protruding from the frame of the device for cardiac surgery from  FIG.  15   . 
         FIGS.  20 A- 20 E  are top perspective, top-right perspective, right perspective, right-rear perspective, and rear perspective views, respectively of another embodiment of a device for cardiac surgery. 
         FIGS.  21 A,  21 B,  21 C,  21 D,  21 E, and  21 F  are rear, top, left side, right side, bottom, and front elevational views, respectively of the device for cardiac surgery from  FIGS.  20 A- 20 E . 
     
    
    
     It will be appreciated that for purposes of clarity and where deemed appropriate, reference numerals have been repeated in the figures to indicate corresponding features, and that the various elements in the drawings have not necessarily been drawn to scale in order to better show the features. 
     DETAILED DESCRIPTION 
       FIG.  1    is a perspective view of one embodiment of a device  40  for cardiac surgery.  FIG.  2    is an exploded view of the device  40  for cardiac surgery from  FIG.  1   . The device  40  has a frame  42  which comprises first and second frame parts  42 A,  42 B. The first and second frame parts  42 A,  42 B are pivotably coupled together by a hinge  44  formed from corresponding first and second hinge features  44 A,  44 B. The corresponding hinge features  44 A,  44 B can be held together, while still allowing rotation about a pivot axis  46 , by using a variety of techniques known to those skilled in the art. In this embodiment, the hinge  44  is made from portions of the first and second frame parts  42 A,  42 B. In other embodiments, a hinge could be a separate part which is coupled between the frame parts  42 A,  42 B. 
     The device  40  for cardiac surgery also has a plurality of suture guides  48 A,  48 B,  50 A,  50 B,  52 A,  52 B. spaced about the frame  42 . While the suture guides  48 A- 52 B may each be used with individual sutures, it is also very useful for the sutures guides  48 A,  48 B;  50 A,  50 B; and  52 A,  52 B to comprise pairs of suture guides  48 ,  50 , and  52 , respectively. As will be discussed later in this specification, each of the pairs of suture guides  48 ,  50 ,  52  can be used with the ends of a single suture. 
     In the embodiment shown in  FIGS.  1  and  2   , the frame  42  also comprises a plurality of tabs  54 A,  54 B,  54 C,  54 D which protrude from the frame  42 . In this embodiment, at least some of the suture guides  48 B,  50 A,  50 B,  52 B are located in respective tabs  54 A,  54 B,  54 C,  54 D. Depending on your perspective, the ends  56 A,  56 B of the frame  42  could also be considered tabs in which respective suture guides  48 A,  52 A have been formed. 
     Generally, the interior of the frame  42  will be the area of surgical focus when the device  40  for cardiac surgery is used. In this embodiment, the tabs  54 A- 54 D protrude from the frame  42  towards an inner side of the frame. 
       FIGS.  3  and  4    are top views of the device  40  for cardiac surgery from  FIG.  1   , the views illustrating the device  40  in an opened and a closed position, respectively. In the open position of  FIG.  3   , the first and second frame parts  42 A,  42 B have pivoted relative to each other about the hinge  44  until a first open stop  58 A and a second open stop  58 B contact each other. The first open stop  58 A is defined by the first frame part  42 A, while the second open stop  58 B is defined by the second frame part  42 B. In this open position (or any of the intervening positions leading up to the fully open position of  FIG.  3   ), the device  40  may more easily be passed from outside the patient, through a minimally invasive opening, and into an interior cavity of the patient, such as the pericardial cavity. In this embodiment, the hinge  44  enables the two parts of the frame  42 A,  42 B to open like a jaw. 
     In the closed position of  FIG.  4   , the first and second frame parts  42 A,  42 B have pivoted relative to each other about the hinge  44  until a first closed stop  60 A and a second closed stop  60 B contact each other. The first closed stop  60 A is defined by the first frame part  42 A, while the second closed stop  60 B is defined by the second frame part  42 B. In this closed position, the device  40  is oriented for use in a cardiac operation, an example of which will be described below. As can be seen in  FIG.  4   , in this embodiment, the frame forms a substantially continuous periphery with one open side  62 . The frame in this embodiment also has a substantially rounded shape. In this embodiment, the plurality of suture guides  48 A,  48 B,  50 A,  50 B,  52 A,  52 B are also aligned to fall substantially on a same circle. Looked at as pairs of suture guides  48 ,  50 ,  52 , in this embodiment, the pairs of suture guides are spaced substantially evenly around a centerpoint of such circle. 
       FIGS.  5 A- 5 D  illustrate one embodiment of a surgical setting and a surgical method where the device for cardiac surgery from  FIG.  1    finds utility.  FIG.  5 A  schematically illustrates a surgical situation. Minimally invasive surgical access has been gained on a patient, for example, through a right atrial mini-thoracotomy (access between two of the patient&#39;s ribs). An incision has been made in the aorta  64 , creating an opening through which the aortic valve and the left ventricle  66  may be accessed. The aortic valve is not visible in  FIG.  5 A  because the valve leaflets were diseased and have been removed. First, second, and third stay sutures  68 A,  68 B,  68 C have been placed by the surgeon at the locations of the valve commissures  70 A,  70 B,  70 C, respectively. The commissures  70 A,  70 B,  70 C are the location on the aortic root where the bases of different valve leaflets (now removed) used to come together. 
     In  FIG.  5 B , the device  40  for cardiac surgery has been positioned against the heart in a closed position, around the surgical opening in the aorta such that the pairs of suture guides  48 ,  50 ,  52  are generally aligned with the stitches in the commissures  70 A,  70 B,  70 C. The first and second ends  72 A,  72 B of the first stay suture  68 A are passed through respective first and second suture guides  48 A,  48 B in the first pair of suture guides  48 . Similarly, the first and second ends  74 A,  74 B of the second stay suture  68 B are passed through respective first and second suture guides  50 A,  50 B in the second pair of suture guides  50 . Similarly, the first and second ends  76 A,  76 B of the third stay suture  68 C are passed through respective first and second suture guides  52 A,  52 B in the third pair of suture guides  52 . The suture ends may be passed through their respective guides using a needle (not shown) or by using a snare (also not shown). 
     In  FIG.  5 C , the first and second suture ends  72 A,  72 B of the first stay suture  68 A have further been passed through a first suture tube  78 A. Similarly, the first and second suture ends  74 A,  74 B of the second stay suture  68 B have further been passed through a second suture tube  78 B. Similarly, the first and second suture ends  76 A,  76 B of the third stay suture  68 C have further been passed through a third suture tube  78 C. The suture ends may be passed through their respective suture tubes using a snare (not shown). Suitable tubes include flexible or rigid tubes which may be used in the fashion of a Rumel tourniquet as known to those skilled in the art.  FIG.  5 D  illustrates one example of such tourniquet usage. The first suture ends  72 A,  72 B of the first stay suture  68 A may be tensioned  80 A while the first suture tube  78 A is held. A first clamp  82 A is placed on the suture ends  72 A,  72 B at the end of the suture tube  78 A to maintain the tension in the first stay suture  68 A. Similarly, the suture ends  74 A,  74 B of the second stay suture  68 B may be tensioned  80 B while the second suture tube  78 B is held. A second clamp  82 B is placed on the suture ends  74 A,  74 B at the end of the suture tube  78 B to maintain the tension in the second stay suture  68 B. Similarly, the suture ends  76 A,  76 B of the third stay suture  68 C may be tensioned  80 C while the third suture tube  78 C is held. A third clamp  82 C is placed on the suture ends  76 A,  76 B at the end of the suture tube  78 C to maintain the tension in the third stay suture  68 C. The tension on the sutures can be adjusted as desired to draw out the aortic root  84 . Further suture stitches will need to be placed around the circumference of the aortic root  84  in order to attach a replacement aortic valve. The device  40  for cardiac surgery helps to draw this target tissue out and improve visualization of both the aortic root and the area of interest for the aortic valve replacement. The suture tubes  78 A- 78 C may also be used as manipulators to help position the underlying tissue by moving the device  40  to which the tissue is attached. 
       FIG.  6    is a top view of another embodiment of a device  86  for cardiac surgery. The device  86  has a frame  88  that is a single piece. In this embodiment, the frame has first, second, and third tabs  90 A,  90 B,  90 C which protrude inward. Suture guides  92 A,  92 B make up a first pair of suture guides  92 . Suture guides  94 A,  94 B make up a second pair of suture guides  94 . Suture guides  96 A,  96 B make up a third pair of suture guides  96 . Each of the first, second, and third pairs of suture guides  92 ,  94 ,  96  are located on a respective first, second, and third tab  90 A,  90 B,  90 C of the frame  88 . As compared to the earlier embodiment, in this embodiment, the suture guides in a given pair of suture guides are also closer together. In this embodiment, however, the pairs of suture guides  92 ,  94 ,  96  are still spaced substantially equally around an imaginary circle through which all of the suture guides pass. 
       FIG.  7    is a top view of a further embodiment of a device  98  for cardiac surgery. The device  98  has a frame  100  which comprises first and second frame parts  100 A,  100 B. The first and second frame parts  100 A,  100 B are pivotably coupled together by a hinge  102  that enables the two parts of the frame  100 A,  100 B to fold on themselves like a book.  FIG.  7    shows the frame  100  in an opened position, but in a folded position, the frame can take up less space and be easier to pass through a minimally invasive surgical opening. Like previous embodiments, the device  98  of  FIG.  7    has a plurality of suture guides  104 A,  104 B,  106 A,  106 B, and  108 A,  108 B distributed around the frame  100 . 
       FIG.  8    is a top view of a portion of a frame  110  on another embodiment of a device for cardiac surgery. In the position of the frame  110  shown in  FIG.  8   , there are first and second initial suture guides  112 A,  112 B which make up a pair of initial suture guides  112 . Each of the initial suture guides  112 A,  112 B is configured to accept suture that has been placed in a tissue. For example, as shown in  FIG.  8   , first and second suture ends  114 A,  114 B, which come from the same suture that has been stitched into a portion of tissue (not shown), have been passed up through the respective initial suture guides  112 A,  112 B. The frame  110  also has a plurality of secondary suture guides, each configured to accept suture from at least one of the initial suture guides  112 A,  112 B or from at least another of the secondary suture guides. In this embodiment, the first suture end  114 A, after having been passed up through the initial suture guide  112 A as described, is then passed down through the secondary suture guide  116 A and back up through the secondary suture guide  118 A. Similarly, the second suture end  114 B, after having been passed up through the initial suture guide  112 B as described, is then passed down through the secondary suture guide  116 B and back up through the secondary suture guide  118 B. The suture ends  114 A,  114 B can then be passed through a suture tube  120  as described with previous embodiments. One possible advantage of the initial and secondary suture guide system of the embodiment in  FIG.  7    is that it allows for a different spacing between the pair of initial suture guides  112 A,  112 B which interface more directly with the tissue as compared to the spacing between the pair of secondary suture guides  118 A,  118 B which interface more directly with the suture tube  120 . In this embodiment, the pair of secondary suture guides  118 A,  118 B are spaced more closely together than the pair of initial suture guides  112 A,  112 B. In some embodiments, such as this one, a wider spacing of the initial suture guides  112 A,  112 B may be more desirable to spread out the stay suture pulling lines for shaping/positioning the aortic root. In some embodiments, such as this one, a more narrow spacing of the secondary suture guides  118 A,  118 B which interface with the suture tube  120  may be more desirable because it more closely couples the suture tube  120  to the frame  110  when the suture ends  114 A,  114 B are under tension. The secondary suture guides also enable the suture tube  120  to be located farther away from the inner side of the frame  110 , which may afford more space for a fragile replacement heart valve to be worked into place without worry of contacting the suture tubes. In still other embodiments, the one or more secondary suture guides can act as alternate primary suture guides, providing a surgeon choices for positioning of the suture when threading it through the primary suture guide of choice. 
       FIG.  9    is a schematic view of a further embodiment of a device  122  for cardiac surgery. The embodiment of  FIG.  9    has many elements in common with the embodiment of  FIG.  1   . For efficiency, the similar elements in the embodiment of  FIG.  9    will include similar identifying numbers and their description will not be repeated. The device  122  has a plurality of suture tubes  124 A,  124 B,  124 C which correspond, respectively, to one of the pairs of suture guides  48 ,  50 ,  52 . The device  122  also has a plurality of snares  126 A,  126 B,  126 C, each corresponding to and passed through a respective suture tube  124 A,  124 B,  124 C. Each of the snares  126 A,  126 B,  126 C has a respective handle  128 A,  128 B,  128 C protruding through a respective proximal end  130 A,  130 B,  130 C of the corresponding respective suture tube  124 A,  124 B,  124 C. Although the snare handles  128 A,  128 B,  128 C are illustrated as something separate from the snare wires in this embodiment, the handles could simply be the ends of the snare or formed from the ends of the snare in other embodiments. Each of the snares  126 A,  126 B,  126 C also has a respective snare loop  132 A,  132 B,  132 C at the other end of the respective snare  126 A,  126 B,  126 C and protruding through a respective distal end  134 A,  134 B,  134 C of the respective corresponding suture tube  124 A,  124 B,  124 C, and wherein each of the snare loops  132 A,  132 B,  132 C further protrudes through a respective one of the suture guides  48 B,  50 A,  52 A in a corresponding, respective pair of suture guides  48 ,  50 ,  52 . 
     The device  122  also has a plurality of sutures  136 A,  136 B,  136 C, each corresponding to one of the respective pairs of suture guides  48 ,  50 ,  52  and coupled to the respective suture guide  48 A,  50 B,  52 B which does not have a snare loop  132 A,  132 B,  132 C passing through it. Each of the sutures  136 A,  136 B,  136 C has a respective needle  138 A,  138 B,  138 C coupled to an end of the suture opposite the other end of the suture which is coupled to the corresponding suture guide. Each of the suture guides  48 A,  50 B,  52 B to which the suture is coupled may be referred to as a suture anchor point. Sutures may be coupled to the suture anchor point (a suture guide) by a tied knot or a mechanical knot. One suitable example of a mechanical knot is the Ti-KNOT® device or the COR-KNOT® device which is manufactured and sold by LSI Solutions, Inc. of Victor, N.Y. (see www.lsisolutions.com). In some embodiments, if a mechanical knot is used, the mechanical knot may be coupled to the frame. 
     One advantage of the device  122  is that it has many of the necessary elements already combined into one assembly. Once the device frame  42  is situated adjacent to the tissue to be worked on, each of the sutures  136 A,  136 B,  136 C may be stitched through a respective commissure of the aortic root, the needles may then be removed from the suture, and then the suture ends where the needles used to be attached may be threaded through a respective snare loop  132 A,  132 B,  132 C in order to draw each of the single suture ends out through a respective suture tube  124 A,  124 B,  124 C. The single suture ends can then be clamped at each respective proximal end  130 A,  130 B,  130 C of the suture tubes  124 A,  124 B,  124 C after the desired suture tension is achieved. 
       FIG.  10    is a perspective view of another embodiment of a device  140  for cardiac surgery. This embodiment is similar to the embodiment of  FIG.  1   , with the exception that the suture guides  142 A,  142 B,  144 A,  144 B,  146 A,  146 B are located on respective frame tabs  148 A,  148 B,  150 A,  150 B,  152 A,  152 B which are bent out of a plane which the remainder of the frame  154  occupies. These bent tabs  148 A,  148 B,  150 A,  150 B,  152 A,  152 B can allow the frame to sit on one part of the heart and/or other adjacent tissue while the tabs  148 A,  148 B,  150 A,  150 B,  152 A,  152 B move the suture guides  142 A,  142 B,  144 A,  144 B,  146 A,  146 B closer to the aortic root. In other embodiments, the tabs could be bent upwards. 
       FIG.  11    is a perspective view of a further embodiment of a device  156  for cardiac surgery. This embodiment is similar to the embodiment of  FIG.  1   , with the addition of a skirt  158  coupled to both parts of the frame  42 A,  42 B. The skirt  158  can have a variety of dimensions and cross-sectional shapes. The skirt  158  can act as a softer tissue interface and may even be absorbent in some embodiments to help keep a surgical field clear. The skirt  158  may also have a resilient shape (elasticity) so that it can also act as a spring member to help return or bias the frame parts  42 A,  42 B to a closed (operating) position in the absence of some greater opening force being applied about the hinge  44 . 
       FIGS.  12  and  13    are top views of another embodiment of a device  160  for cardiac surgery, shown in closed and open positions, respectively. The embodiment of  FIGS.  12  and  13    is similar to the embodiment of  FIG.  1   , but the frame  162  (comprising first and second frame parts  162 A,  162 B) has a substantially polygonal shape when in the closed (operating) position of  FIG.  12   . Similar to the embodiment of  FIG.  1   , the device  160  of  FIGS.  12  and  13    has a plurality of suture guides  164 A,  164 B,  166 A,  166 B,  168 A,  168 B, each of which is located on a respective tab  170 A,  170 B,  172 A,  172 B,  174 A,  174 B. In this embodiment, however, the suture guides  164 A,  164 B,  166 A,  166 B,  168 A,  168 B are distributed substantially equally around a circle through which they all pass (approximately every 60 degrees). 
     While the tabs  170 A,  170 B,  172 A,  172 B,  174 A,  174 B of the device  160  lie substantially in the same plane as the frame  162 , the tabs  170 A,  170 B,  172 A,  172 B,  174 A,  174 B may be configured to be bent, thereby enabling a surgeon to customize the position of the suture guides  164 A,  164 B,  166 A,  166 B,  168 A,  168 B relative to the frame in order to accommodate differing patient anatomies. In some embodiments, the tabs may be pre-bent in a recommended or starting configuration. In some embodiments, one or more of the tabs may be configured to be bent in more than one location. 
       FIGS.  14 A and  14 B  are top views of a further embodiment of a device  176  for cardiac surgery, the views illustrating the device in a closed and an opened position, respectively. The device  176  has a frame  178  which comprises first and second frame parts  178 A,  178 B. The first and second frame parts  178 A,  178 B are pivotably coupled together by a hinge point  180 . 
     The device  176  for cardiac surgery also has a plurality of suture guides  182 A,  182 B,  184 A,  184 B,  186 A,  186 B spaced about the frame  178 . While the suture guides  182 A- 186 B may each be used with individual sutures, it is also very useful for the sutures guides  182 A,  182 B;  184 A,  184 B; and  186 A,  186 B to comprise pairs of suture guides  182 ,  184 , and  186 , respectively. As with previous embodiments in this specification, each of the pairs of suture guides  182 ,  184 ,  186  can be used with the ends of a single suture. 
     In the embodiment shown in  FIGS.  14 A and  14 B , the frame  178  also comprises a plurality of tabs  188 A,  188 B,  190 A,  190 B,  192 A,  192 B which protrude from the frame  178 . In this embodiment, the tabs  188 A- 192 B are raised up to a different plane than the first and second frame parts  178 A,  178 B by extensions  194 A,  194 B,  194 C. Other embodiments might not have extensions and the tabs could lie in substantially the same plane. In still other embodiments, the tabs could be bendable or bent in such a way as to allow at least some of the suture guides to be in a substantially different plane from the first and second frame parts  178 A,  178 B. In this embodiment, the suture guides  182 A,  182 B,  184 A,  184 B,  186 A,  186 B are located in respective tabs  188 A,  188 B,  190 A,  190 B,  192 A,  192 B. 
     In this embodiment, the device  176  also has a drive screw  196  which has a groove (not visible in these views) which is held by a clip  198  within a cylindrical plug  200  pivotably coupled within the first frame part  178 A. The drive screw  196  can be rotated within the cylindrical plug  200 , but cannot translate due to the clip  198 . A flexible drive extension  202  may be coupled to the drive screw  196  for remotely turning the drive screw  196 . The drive screw  196  has threads  204  which engage a threaded cylindrical plug  206  that is pivotably coupled to the second frame part  178 B. Therefore, when the drive screw  196  is turned in a first direction, the first and second frame parts  178 A,  178 B will tend to close towards a closed position such as illustrated in  FIG.  14 A . Similarly, when the drive screw  196  is turned in a second direction, the first and second frame parts  178 A,  178 B will tend to open towards an opened position such as illustrated in  FIG.  14 B . 
     In the embodiment of  FIGS.  14 A,  14 B , the first and second frame parts  178 A,  178 B have one or more voids  208  which open to the underside of the frame parts  178 A,  178 B. Corresponding skirt material may be inserted into the one or more voids  208  in order to provide a more compliant tissue interface for the device  176 . 
       FIGS.  15  and  16    are perspective and top views, respectively, of another embodiment of a device  210  for cardiac surgery. The device  210  has a frame  212  that is a single piece. In other embodiments, however, the frame  212  could be in one or more parts which are movable relative to each other. In this embodiment, the frame has first, second, and third tabs  214 A,  214 B,  214 C which protrude upward from the frame and then arch inward. Suture guides  216 A,  216 B make up a first pair of suture guides  216 . Suture guides  218 A,  218 B make up a second pair of suture guides  218 . Suture guides  220 A,  220 B make up a third pair of suture guides  220 . Each of the first, second, and third pairs of suture guides  216 ,  218 ,  220  are located on a respective first, second, and third tab  214 A,  214 B,  214 C of the frame  212 . In this embodiment, the suture guides  216 A,  216 B,  218 A,  218 B,  220 A,  220 B are tapered with the guides being more narrow on the bottom side than the top. Also in this embodiment, the tabs  214 A,  214 B,  214 C have each been reinforced with a respective stabilizer  222 A,  222 B,  222 C to help keep the tabs  214 A,  214 B,  214 C from bending. Other embodiments may not have stabilizers. As viewed from the top view of  FIG.  16    in this embodiment, the suture guides  216 A,  216 B,  218 A,  218 B,  220 A,  220 B each substantially fall on the same imaginary circle. 
       FIGS.  17 A,  17 B,  17 C,  17 D,  17 E, and  17 F  are top, left, right, bottom, rear, and front elevational views, respectively, of the device  210  for cardiac surgery from  FIG.  15   . 
       FIG.  18    is a side view of one of the tabs  214 B protruding from the frame  212  of the device  210  for cardiac surgery from  FIG.  15   . In this embodiment, the end  224  of the tab  214 B which is away from the frame  212  (and in which the suture guides are formed, but not visible in this view) is substantially parallel to the frame  212 . 
       FIGS.  19 A and  19 B  are bottom and top perspective views, respectively of one of the tabs  214 B protruding from the frame  212  of the device  210  for cardiac surgery from  FIG.  15   .  FIGS.  19 A and  19 B  offer another vantage point to appreciate the tapered suture guide holes  218 A,  218 B of this embodiment. Other embodiments may not have tapered guide holes or the suture guide holes may be tapered in a different direction. Still other embodiments may have suture guide holes which are tapered outward (wider) where they exit on both sides of the tab/frame. 
       FIGS.  20 A- 20 F  are top perspective, top-right perspective, right perspective, right-rear perspective, and rear perspective views, respectively of another embodiment of a device  226  for cardiac surgery. The device  226  has a frame  228  from which support legs  230 ,  232  extend downward. Each support leg  230 ,  232  terminates in a respective support foot,  234 ,  236 . This embodiment has three pairs  238 A,  238 B,  238 C of suture guides  240  spaced about the frame  228 . The suture guides  240  may be used as described for the suture guides of previous embodiments. The device  226  also has two sinus supports  242 ,  244  which extend outward from the frame  228 . The sinus supports  242 ,  244  are each shaped to support an aortic sinus. An aortic sinus is one of the anatomic dilations of the ascending aorta which occurs just above the aortic valve. There are generally three aortic sinuses, one anterior and two posterior. The left posterior aortic sinus gives rise to the left coronary artery and the anterior artic sinus gives rise to the right coronary artery. During cardiac surgery, it is sometimes desirable to have fluid access to the coronary arteries, for example, to deliver solutions which can stop and start the heart. When an aortotomy is made to gain access to the aortic valve and/or other areas of the heart, the walls of the coronary sinuses may slump down, making it difficult to access the coronary arteries. The sinus supports  242 ,  244  are sized to fit into the coronary sinuses and hold the coronary sinuses open during a cardiac surgical procedure so that fluids may be administered to the coronary arteries, if desired. Maintaining the shape of the coronary sinuses may also help surgeons to visualize the anatomy of the area in which they are operating. Different devices  226  may be provided with sinus supports  242 ,  244  of different sizes, to accommodate natural anatomic variations which occur from person to person. 
       FIGS.  21 A,  21 B,  21 C,  21 D,  21 E, and  21 F  are rear, top, left side, right side, bottom, and front elevational views, respectively of the device for cardiac surgery from  FIGS.  20 A- 20 E . 
     Various advantages of a device for cardiac surgery have been discussed above. Embodiments discussed herein have been described by way of example in this specification. It will be apparent to those skilled in the art that the foregoing detailed disclosure is intended to be presented by way of example only, and is not limiting. Various alterations, improvements, and modifications will occur and are intended to those skilled in the art, though not expressly stated herein. These alterations, improvements, and modifications are intended to be suggested hereby, and are within the spirit and the scope of the claimed invention. As just one example, although many of the embodiments shown herein included six suture guides, it should be understood that other embodiments may have more or fewer suture guides. As another non-limiting example, the suture guide holes shown in the embodiments herein are fully constrained holes. In other embodiments, the suture guide holes could be in communication with an access channel that would allow a suture to be brought into the suture guide hole by guiding a middle portion of a suture through the access channel and into the suture guide hole. This could avoid the need for a snare to pull the suture through the guide hole in some embodiments. Additionally, the recited order of processing elements or sequences, or the use of numbers, letters, or other designations therefore, is not intended to limit the claims to any order, except as may be specified in the claims. Accordingly, the invention is limited only by the following claims and equivalents thereto.