The Acorn Procedure  Vinay Badhwar, Steven F. Bolling  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 7, Issue 2, Pages 84-89 (May 2002) DOI: 10.1053/otct.2002.32180 Copyright © 2002 Elsevier Inc. Terms and Conditions

Fig 1 Although many cardiomyopathy patients with mitral regurgitation (MR) can be effectively managed with geometric mitral reconstruction occasionally patients with preoperative LV enddiastolic dimensions exceeding 70 mm may continue to dilate postoperatively.1 Therefore, whether for use in conjunction with mitral reconstruction or as a stand-alone surgical therapy, a simple and effective method to halt progressive ventricular dilation can appreciably impact the long-term outcome of heart failure patients. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 84-89DOI: (10.1053/otct.2002.32180) Copyright © 2002 Elsevier Inc. Terms and Conditions

1 Although the CSD may be effectively placed without the use of CPB using various off-pump techniques used for posterior exposure, preparations for CPB are recommended. CPB is used to avoid precipitating hemodynamic alterations and arrhythmias during placement of posterior sutures, or if the patient requires concomitant mitral valve reconstruction (MVr). Once the beating heart is supported on CPB, the CSD is positioned around the heart and its upper margin is placed adjacent to the AV groove, with the smooth surface of the CSD against the epicardium. Interrupted 4-0 nonabsorbable tacking sutures with tapered noncutting needles are then placed posteriorly and laterally 2–3 cm apart, just below the AV groove, with care taken to not hit any epicardial vessels. Once the posterior sutures are in place, if the patient requires MVr, this is performed in the standard fashion. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 84-89DOI: (10.1053/otct.2002.32180) Copyright © 2002 Elsevier Inc. Terms and Conditions

2 The CSD is brought around the ventricles to avoid wrinkles in the fabric as the patient is weaned from CPB. To custom-fit the CSD, the excess fabric is gathered along the anterior seam of the device. The nontoothed Acorn curved fitting clamp is used to help gather the excess material and custom-size the CSD to the patient. Baseline loading conditions should be optimized at this time as a repeat left ventricular end-diastolic dimension (LVEDD) measurement is obtained by TEE. When fitting the CSD, care must be taken to ensure that the LVEDD is reduced from baseline by no more than 10%. The tension should be evenly distributed over the entire circumference of the device. The fit should provide complete contact with the ventricular walls throughout the cardiac cycle with no evidence of hemodynamic compromise. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 84-89DOI: (10.1053/otct.2002.32180) Copyright © 2002 Elsevier Inc. Terms and Conditions

3 Once the fit is establisbed, running a 4-0 or stronger horizontal mattress nonabsorbable suture flush below the clamp creates a new seam. The excess material is then trimmed. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 84-89DOI: (10.1053/otct.2002.32180) Copyright © 2002 Elsevier Inc. Terms and Conditions

4 (A) The clamp is removed, and the anterior seam is reinforced with a running 4-0 nonabsorbable suture beginning at the apex to enable length adjustment while suturing. The final anterior tacking sutures are then placed along the AV groove. (B) The final fit of the CSD is completed by ensuring that the device covers the epicardium throughout the entire cardiac cycle and that the reduction in LVEDD does not exceed 10% of baseline. If TEE is not available, the Acorn tape measure is used to compare baseline measurements taken at the same location. Before decannulation, the surgeon should also ensure that there are no obstructions to epicardial vessels along the AV groove and that no fabric damage exists that may require suture repair. The patient is then decannulated, the mediastinum is irrigated, and the sternotomy is closed after placement of standard drainage catheters. Operative Techniques in Thoracic and Cardiovascular Surgery 2002 7, 84-89DOI: (10.1053/otct.2002.32180) Copyright © 2002 Elsevier Inc. Terms and Conditions