Automated titanium fastener for surgical aortic valve replacement-preventive role for infective endocarditis?

OBJECTIVES

Evidence on long-term clinical outcomes considering suture-securing techniques used for surgical aortic valve replacement is still uncertain.

METHODS

A total of 1405 patients who underwent surgical aortic valve replacement between January 2016 and December 2022 were included and grouped according to the suture-securing technique used (automated titanium fastener versus hand-tied knots). The occurrence of infective endocarditis during follow-up was set as the primary study end-point. As secondary study end-points, stroke, all-cause mortality and a composite outcome of either infective endocarditis, stroke, or all-cause mortality were assessed.

RESULTS

The automated titanium fastener was used in 829 (59%) patients, whereas the hand-knot tying technique was used in 576 (41%) patients. The multivariable proportional competing risk regression analysis showed a significantly lower risk of infective endocarditis during follow-up in the automated titanium fastener group (adjusted sub-hazard ratio 0.44, 95% confidence interval 0.20-0.94, P = 0.035). The automated titanium fastener group was not associated with an increased risk of mortality or attaining the composite outcome, respectively (adjusted hazard ratio 0.81, 95% confidence interval 0.60-1.09, P = 0.169; adjusted hazard ratio 0.82, 95% confidence interval 0.63-1.07, P = 0.152). This group was not associated with an increased risk of stroke (adjusted sub-hazard ratio 0.82, 95% confidence interval 0.47-1.45, P = 0.504). Also, a significantly lower rate of early-onset infective endocarditis was observed in the automated titanium fastener group, (0.4% vs 1.4%, P = 0.032).

CONCLUSIONS

Suture-securing with an automated titanium fastener device appears to be superior compared to the hand-knot tying technique in terms of lower risk of infective endocarditis.

Early Outcomes of Minimally Invasive Right Anterior Thoracotomy vs. Median Full Sternotomy in Isolated Aortic Valve Replacement: A Propensity Score Analysis

INTRODUCTION

This study aimed to compare the early postoperative outcomes of right anterior thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery with those of median full sternotomy aortic valve replacement (MFS-AVR) approach with the goal of identifying potential benefits or drawbacks of each technique.

METHODS

This retrospective, observational, cohort study included 476 patients who underwent RAT-MIAVR or MFS-AVR in our hospital from January 2015 to January 2023. Of these, 107 patients (22.5%) underwent RAT-MIAVR, and 369 patients (77.5%) underwent MFS-AVR. Propensity score matching was used to minimize selection bias, resulting in 95 patients per group for analysis.

RESULTS

After propensity matching, two groups were comparable in preoperative characteristics. RAT-MIAVR group showed longer cardiopulmonary bypass time (130.24 ± 31.15 vs. 117.75 ± 36.29 minutes, P=0.012), aortic cross-clamping time (76.44 ± 18.00 vs. 68.49 ± 19.64 minutes, P=0.004), and longer operative time than MFS-AVR group (358.47 ± 67.11 minutes vs. 322.42 ± 63.84 minutes, P=0.000). RAT-MIAVR was associated with decreased hospitalization time after surgery, lower postoperative blood loss and drainage fluid, a reduced incidence of mediastinitis, increased left ventricular ejection fraction, and lower pacemaker use compared to MFS-AVR. However, there was no significant difference in the incidence of major complications and in-hospital mortality between the two groups.

CONCLUSION

RAT-MIAVR is a feasible and safe alternative procedure to MFS-AVR, with comparable in-hospital mortality and early follow-up. This minimally invasive approach may be a suitable option for patients requiring isolated aortic valve replacement.

Automated titanium fastener vs. hand-tied knots for prosthesis fixation in infective endocarditis

Objectives

To date, there is no evidence regarding the safety of automated titanium fastener compared with hand-tied knots for prosthesis fixation in infective endocarditis.

Methods

Between January 2016 and December 2022, a total of 220 patients requiring surgery for infective endocarditis were included in this retrospective analysis. The primary study endpoint was re-endocarditis during follow-up. The secondary study endpoints included stroke onset, all-cause mortality, and a composite outcome of either re-endocarditis, stroke, or all-cause mortality during follow-up.

Results

Suture-securing with an automated titanium fastener was performed in 114 (51.8%) patients, whereas the conventional technique of hand knot-tying was used in 106 (48.2%) patients. The risk of re-endocarditis was significantly lower in the automated titanium fastener group, as shown in a multivariable proportional competing risk regression model (adjusted sub-hazard ratio 0.33, 95% confidence interval 0.11-0.99, p = 0.048). The multivariable Cox proportional hazards regression analysis showed that the automated titanium fastener group was not associated with an increased risk of stroke-onset or attaining the composite outcome, respectively, (adjusted hazard ratio 0.54, 95% confidence interval 0.27-1.08, p = 0.082), (adjusted hazard ratio 0.65, 95% confidence interval 0.42-1.02, p = 0.061). Also, this group was not associated with an increased risk of all-cause mortality, as demonstrated in the multivariable Poisson regression analysis (adjusted incidence-rate ratio 1.42, 95% confidence interval 0.83-2.42, p = 0.202).

Conclusions

The use of automated titanium fastener device seems to be safe for infective endocarditis. Analyses of larger cohorts are required.

Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve

OBJECTIVE

Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR.

METHODS

There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded.

RESULTS

In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05).

CONCLUSIONS

The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.

Safety and Effectiveness Outcomes of a Novel Automated Titanium Suture Fastener Device Applied for Heart Valve Surgery in an Ovine Model

Objective

This study was designed to evaluate the operability, effectiveness, and safety of the automated titanium suture fastener in a preclinical ovine model in comparison with manual tying in a mitral valve annuloplasty ring implantation surgery.

Methods

Eighteen adult Small-tailed Han sheep were prepared for the surgery of mitral valve annuloplasty ring implantation through lateral thoracotomy under cardiopulmonary bypass (CBP). A total of 12 stitches were performed to secure an annuloplasty ring, with 6 stitches done with the automated fastener and the other 6 by manual tying. The knotting time for the automated fastener or manual tying was recorded, respectively. The firmness of knots, mitral valve integrity, biocompatibility, thrombosis, local reactions, and other aspects were also compared at follow-up time (Days 30, 60, 90, and 180).

Results

Of the 18 sheep, 16 survived to the designated endpoints and were enrolled for further analysis. Compared with the control group, the knotting time was significantly reduced with the automated fastener (p < 0.01). All the annuloplasty rings were tightly secured by 6 fastener clips and 6 hand-made knots without any disengagement or displacement. All the mitral valves were intact without any defect, stenosis, prolapse, valve insufficiency, or perforation. Endothelialization was comparable between the two groups by Day 60. Small red thrombi formed at the thread end of the suture in both groups. No thrombus was found on the surface of the titanium clip. All the thrombi were within the acceptable range for the antithrombotic property. Thrombosis showed no significant difference by Day 60. No significant differences in the inflammatory response and pathological lesions were observed by Day 60. One case of diffuse renal infarction (area ratio = 20%) and 1 case of small focal renal infarction (area ratio < 5%) were caused by thromboembolism.

Conclusions

The automated fastener significantly shortened the procedure time of tying knots for the implantation of the annuloplasty ring in the ovine model, with comparable safety and effectiveness as manual tying.

How We Perform a David Procedure With an Upper Hemisternotomy Approach

OBJECTIVE

Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183-208] vs 212 [183-223] min, P = 0.309) and aortic cross-clamp (169 [155-179] vs 188 [155-199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

Automated Suture Fastener Gaining Complete Commitment: Cumulative Propensity-Matched Comparison with Hand-Tied Knot in Heart Valve Surgery

OBJECTIVE

The COR-KNOT® device is an automated suture fastener in which there is currently no consensus on its role in heart valve surgery. Our aim was thus to conduct a one-to-one comparison of clinical outcomes with a hand-tied control cohort.

METHODS

We performed a single-center, cumulative propensity-matched retrospective cohort study on patients undergoing heart valve surgery from 1 January 2015 to 13 February 2020. Propensity score matching was performed on 693 patients, dividing them into matched COR-KNOT® (n = 124) and hand-tied (n = 124) groups.

RESULTS

Data on baseline demographics, operative details, and clinical outcomes were analyzed and compared between the groups. The patients in both the COR-KNOT® and control groups were well-matched. For the median sternotomy (MS) all procedures subgroup, use of COR-KNOT® was associated with a decrease of around 49 min in CPB time (220.00 [168.00 to 256.00] vs 70.50 [134.00 to 236.75] min, P = 0.006) and around 32 min in ACC time (145.00 [109.00 to 189.00] vs 112.50 [81.00 to 161.75] min, P = 0.008). In the MS valve and CABG subgroup, use of COR-KNOT® was associated with a 70 min reduction in overall operation time (401.00 [354.25 to 468.75] vs 330.50 [288.50 to 370.50] min, P = 0.013), 63 min reduction in CPB time (216.50 [191.75 to 283.25] vs 153.00 [124.75 to 207.50] min, P = 0.004) and 45 min reduction in ACC time (146.00 [134.50 to 205.50] vs 100.50 [71.50 to 150.75] min, P = 0.003).

CONCLUSIONS

In heart valve surgery, use of the automated suture fastener was associated with shorter CPB and ACC times. Additionally, we determined that clinical outcomes are most likely unaffected by the use of COR-KNOT®.

The mini-Bentall approach: Comparison with full sternotomy

Background

The upper mini sternotomy Bentall (mini-Bentall) procedure may result in less trauma and earlier recovery compared with the full sternotomy Bentall procedure (full Bentall). This study compares immediate and 1- and 3-year survival rates after mini- and full Bentall procedures.

Methods

Between February 2009 and July 2019, 48 patients underwent a mini-Bentall and 49 underwent a full Bentall. Patients who required concomitant procedures, reoperations, or hypothermic circulatory arrest were excluded from our analysis. The mean patient age was 60.7 years in the mini-Bentall group and 59.0 years in the full Bentall group.

Results

There were no in-hospital mortalities. The median cardiopulmonary bypass time (mini-Bentall: 165 minutes [interquartile range (IQR), 155.5-183 minutes]; full Bentall: 164 minutes [IQR, 150-187 minutes]; P = .619) and aortic cross-clamp times (139 minutes [IQR, 128.5-153 minutes] vs 137 minutes [IQR, 125-156 minutes]; P = .948) were not significantly different between the 2 groups. The mini-Bentall group had a significantly shorter median ventilation time compared with the full Bentall group (5.5 hours [IQR, 3-14 hours] vs 17 hours [IQR, 11-23 hours]; P < .001). None of the patients in the mini-Bentall group had postoperative bleeding necessitating reoperation, whereas 4 patients (8.2%) underwent reoperation after full Bentall (P = .043). The mini-Bentall group also had a shorter median hospital length of stay (6 days [IQR, 5-8 days] vs 7 days [IQR, 6-8 days]; P = .086). Survival at 1 and 3 years was 100% in both cohorts.

Conclusions

Patients required significantly less ventilation time and reoperations for bleeding after the mini-Bentall procedure. There were no significant differences in cardiopulmonary bypass, aortic cross-clamp times, or intensive care unit and hospital length of stay between the mini-Bentall and full Bentall groups. The mini-Bentall approach is associated with low morbidity and mortality.

Assessment of pain, anxiety and depression, and quality of life after minimally invasive aortic surgery

BACKGROUND

Minimally invasive cardiac surgery may reduce surgical trauma, diminish postoperative pain and improve quality of life (QOL). The aim of this study is to assess pain, hospital anxiety and depression scale (HADS), and QOL in patients undergoing minimally invasive aortic surgery.

METHODS

This is a prospective, single-center cohort study of 24 consecutive patients undergoing upper ministernotomy aortic valve, aortic root, and concomitant aortic valve and ascending aorta replacement. Visual analog scale (VAS) pain scores and HADS and Short-Form-36 (SF-36) questionnaires were evaluated at preoperative baseline, during hospitalization, and at 1 and 3 months postoperatively.

RESULTS

At discharge, the average VAS pain score was significantly lower than postoperative Day 1 (2.7 ± 0.4 vs. 6.5 ± 0.4; p ≤ .001). By 1 month, the pain scores were not significantly different from baseline (1.7 ± 0.4 vs. 1.0 ± 0.4; p = 1.000), and by 3 months, pain scores returned to baseline (1.0 ± 0.4; p = 1.000). HADS scores show that compared with preoperative baseline, average anxiety scores decreased by 1 month (3.1 ± 0.7 vs. 4.3 ± 0.6; p = 1.000) and decreased significantly by 3 months (1.8 ± 0.7 vs. 4.3 ± 0.6; p = .012). Additionally, depression scores were unchanged at 1 month (3.0 ± 0.4 vs. 3.1. ± 0.4; p = 1.000) and decreased by 3 months (1.3 ± 0.5 vs. 3.0 ± 0.4; p = .060). SF-36 scores revealed no changes in scores in 7 of 8 domains at 1 month and a significant increase in "physical functioning," "energy," and "general health" domains compared to preoperative baseline at 3 months.

CONCLUSIONS

Following minimally invasive aortic surgery, VAS pain scores, HADS and scores in 7 of 8 SF-36 domains returned to preoperative baseline or improved compared to preoperative baseline at 1 month. At 3 months, scores in 3 of 8 SF-36 domains significantly improved compared to preoperative baseline. Larger studies are necessary for further investigation.

Automated Fastener vs Hand-tied Knots in Heart Valve Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Although several studies revealed that the Cor-knot automated fastener (LSI Solutions, Victor, NY) reduces aortic cross-clamp and cardiopulmonary bypass times, the influence of the device on postoperative morbidity and mortality still needs to be evaluated. The aim of this study was to verify the hypothesis that the use of the Cor-knot device for heart valve surgery reduces aortic cross-clamp and cardiopulmonary bypass times, and this time saving translates into reduced morbidity and mortality.

METHODS

Retrospective cohort studies and randomized controlled trials reporting on the use of the automated fastener vs hand-tied knots were reviewed. The following end points were compared: aortic cross-clamp and cardiopulmonary bypass times, postoperative valvular regurgitation, postoperative ejection fraction, prolonged ventilator support, renal failure, and mortality.

RESULTS

Eight studies reporting data on 942 patients were included in the final analysis. The Cor-knot device was associated with shorter cardiopulmonary bypass (mean difference [MD], -11.74; 95% confidence interval [CI], -14.54 to -8.93; P < .00001) and aortic cross-clamp times (MD, -14.36; 95% CI, -19.63 to -9.09; P < .00001) in minimally invasive heart valve procedures. Overall, lower rates of postoperative valvular regurgitation (risk ratio [RR], 0.40; 95% CI, 0.26 to 0.62; P < .0001) and prolonged ventilator support (RR, 0.29; 95% CI, 0.13 to 0.65; P = .003) were observed. No difference was observed in postoperative atrial fibrillation, ejection fraction, renal failure, and mortality.

CONCLUSIONS

The use of the Cor-knot device in heart valve surgery reduced aortic cross-clamp and cardiopulmonary bypass times. Furthermore, as compared with hand-tie methods, the automated fastener may lead to decreased rates of prolonged ventilator support and valvular regurgitation while being noninferior in terms of other postoperative outcomes and mortality.

Transcatheter and ministernotomy aortic valve replacement after bioprosthetic valve failure

BACKGROUND

Transcatheter valve-in-valve implantation (TViV) and minimally invasive reoperative aortic valve replacement (MIrAVR) have rapidly increased as alternatives to conventional reoperative surgical AVR. This study reports a single-center experience of patients undergoing TViV and MIrAVR after bioprosthetic valve failure.

METHODS

In this retrospective review between March 2009 and October 2018, 68 patients without reoperative full sternotomies, concomitant procedures, active endocarditis, and prior homografts or coronary artery bypass grafting underwent isolated AVR for degenerated aortic bioprostheses. Society of Thoracic Surgeons (STS) risk scores and age are reported as median (interquartile range [IQR]) and length of stay is reported as mean (standard deviation [SD]) due to their characteristics of the distribution.

RESULTS

Forty-one (60.3%) patients underwent TViV, and 27 (39.7%) patients underwent MIrAVR. Median [IQR] STS risk scores were 5.7 [4.0-7.8] and 2.0 [1.5-3.4] for TViV and MIrAVR, respectively (p ≤ .001). The median [IQR] age for TViV patients was higher (78 [71-84] vs. 66 [53-72] years, p ≤ 0.001). More permanent pacemakers were implanted (22.2% vs. 9.8%) following MIrAVR. The MIrAVR group had a higher rate of atrial fibrillation (18.5% vs. 9.8%, p = .466). Average (SD) length of stay was less in TViV (5.3 days, SD: 3.4 vs. 8.6 days, SD: 7.4, p = .001). Survival at 1 year was not significantly different for TViV and MIrAVR (94.9% [95% confidence interval [CI]: 81.0%, 98.7%] and 86.9% [95% CI: 64.0%, 95.7%], respectively [p = .969]).

CONCLUSIONS

Despite being at higher-risk, patients undergoing TViV had reduced rates of permanent pacemaker implantations and atrial fibrillation, and a shorter hospital stay as compared to MIrAVR. Survival at 1-year was similar between the two groups.

What is the safety and efficacy of the use of automated fastener in heart valve surgery?

INTRODUCTION

Cor-Knot automated fastener has been used as an adjunct in heart valve surgery to eliminate the need for manual tying during valve implantation. Although reduced operative time and facilitation for minimally invasive surgery are clear benefits, whether their use translates to improved patient outcome remains debatable. This study aims to review the safety and efficacy of automated fasteners in heart valve surgeries.

METHOD

Specific searches were conducted via online medical databases (Pubmed, Embase, Ovid) between 1950 and June 2019. Longitudinal studies were included that provided operative parameters.

RESULTS

The initial literature search identified 3773 articles, but only eight met the inclusion criteria and were used for analysis: four studies related to aortic valve replacement (AVR), four related to mitral valve (MV) intervention (total n = 810). The meta-analysis revealed the significantly shorter aortic cross-clamp time in the Cor-knot group compared to manual tying, both in AVR and MV surgeries (P < .05). Cardiopulmonary bypass time was significantly shorter in the Cor-knot group when analyzing studies in MV surgery (weighted mean difference [WMD]: 110.0; 95% confidence interval: 12.3-207.7; P = .027) The use of Cor-Knot did not increase the risk of permanent pacemaker implantation, paravalvular leak, and 30-day mortality. The majority of studies reported no change in the length of intensive unit care and total hospital stay.

CONCLUSION

We confirmed that the majority of existing literatures indicated the safety and intraoperative efficacy with automated fastener application. Nevertheless, there is currently no evidence to support automated fastened sutures can translate its intraoperative advantages to improved patient outcome.

Aortic valve approaches in the era of minimally invasive cardiac surgery

The concept of minimally invasive cardiac surgery has been gradually adopted world-wide since its inception more than 2 decades ago. Recently, catheter intervention has been used in the treatment of structural heart disease. Most notably, minimally invasive transcatheter aortic valve implantation is now an established treatment option for aortic valve stenosis. There are three major approaches for minimally invasive aortic valve surgery: via median sternotomy, via the parasternal approach, and via the thoracotomy approach. All these approaches allow for a small skin incision and/or avoid full sternotomy. Moreover, several advanced variations with additional aortic procedures or totally endoscopic management have been developed. When considering each approach, low invasiveness must be balanced with safety, as surgeons broaden their insight of advanced medicine. Physical invasiveness is largely related to the surgical approach in minimally invasive surgery. We review the history and evolution of the different surgical approaches for minimally invasive aortic valve replacement.

Ministernotomy aortic valve surgery in patients with prior patent mammary artery grafts after coronary artery bypass grafting

OBJECTIVES

Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts.

METHODS

From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve.

RESULTS

The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively.

CONCLUSIONS

Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.

Titanium Fastener Utilization During HeartMate 3 Left Ventricular Assist Device Implantation

OBJECTIVE

The objective of this study was to investigate the feasibility of using titanium fasteners for securement of the inflow sewing ring during HeartMate 3 implantation. The secondary objective was to compare cardiopulmonary bypass and total operative times between the titanium fastener and hand-tied knot groups.

METHODS

Clearance between the sewing ring and the HeartMate 3 device was assessed in vitro. Thirty-one patients undergoing HeartMate 3 implantation via median sternotomy at a single center from April 2017 to February 2018 were reviewed. The sewing ring was secured with hand-tied knots (n = 18) or titanium fasteners (n = 13). Cannulation strategy and implantation technique were otherwise identical between groups. Central arterial and venous cannulation was performed for cardiopulmonary bypass. The left ventricular apex was cored, and the sewing ring was attached with hand-tied knots or titanium fasteners.

RESULTS

There was adequate clearance for the titanium fastener to secure the inflow sewing ring and then connect to the HeartMate 3 in vitro. The inflow sewing ring was successfully secured during HeartMate 3 implantation in the titanium fastener group. Cardiopulmonary bypass time was 75 and 92 minutes for the titanium fastener and hand-tied groups, respectively (P < 0.03). Total operative time was 177 and 193 minutes for the titanium fastener and hand-tied groups, respectively (P = 0.513).

CONCLUSIONS

The inflow sewing ring of the HeartMate 3 was efficiently secured using titanium fasteners. Titanium fasteners resulted in shorter cardiopulmonary bypass times compared with the hand-tied group. There was no difference in total operative time.