Automated fastener versus manually tied knots in minimally invasive mitral valve repair: impact on operation time and short- term results

Efficacy of automated fasteners versus hand-tied knots in cardiac surgery: a systematic review and meta-analysis

Valve surgery is common in cardiac procedures, with fasteners like COR-KNOT® and hand-tied knots used for knot securing. This study compares their efficacy in valve surgery patients. We searched PubMed, SCOPUS, and Cochrane Central until August 2023. Outcomes assessed included aortic cross-clamp time (AXT), cardiopulmonary bypass (CPB) time, valvular regurgitation, mortality, prolonged ventilatory support, atrial fibrillation, postoperative left ventricular ejection fraction (LVEF), and renal failure. Subgroup analysis was performed for minimally invasive and open cardiac surgery. We used a random effects model for analysis. We included eight observational studies and two randomized controlled trials (RCTs) with a total of 1.411 participants. COR-KNOT significantly reduced AXT [MD -15.14, 95 % CI (-18.57, -11.70), P<0.00001] and CPB time [MD -12.38, 95 % CI (-14.99, -9.77), P<0.00001]. Valvular regurgitation [RR 0.40, 95 % CI (0.26, 0.61), P<0.0001] and need for prolonged ventilatory support [RR 0.29, 95 % CI (0.13, 0.65), P=0.003] were significantly lower with COR-KNOT. There were no significant differences in mortality [RR 0.39, 95 % CI (0.09, 1.69), P=0.44], atrial fibrillation [RR 1.03, 95 % CI (0.83, 1.27), P=0.81], LVEF changes [MD 0.05, 95 % CI (-1.37, 1.47), P = 0.95], or renal failure [RR 0.87, 95 % CI (0.16, 4.80), P = 0.87]. COR-KNOT devices reduce operative time and valvular regurgitation without increasing mortality or adverse outcomes. This supports their use in enhancing surgical efficiency and patient outcomes. However, ongoing discussions about suturing techniques, especially in minimally invasive procedures, highlight the need for further research and consensus among practitioners. See also the graphical abstract(Fig. 1).

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.

A qualitative improvement program for minimally invasive mitral surgery: technical advancements ameliorate outcome and operative times

OBJECTIVES

Minimally invasive mitral valve surgery (MIMVS) has evolved over the last 2 decades. The aim of the study was to identify the impact of era and technical improvements on perioperative outcome after MIMVS.

METHODS

A tota of 1000 patients (mean age: 60.8 ± 12.7 years, 60.3% male) underwent video-assisted or totally endoscopic MIMVS between 2001 and 2020 in a single institution. Three technical modalities were introduced during the observed period: (i) 3D visualization, (ii) use of premeasured artificial chordae (PTFE loops) and (iii) preoperative CT scans. Comparisons were made before and after the introduction of technical improvements.

RESULTS

A total of 741 patients underwent isolated mitral valve (MV) procedure, whereas 259 received concomitant procedures. These consisted of tricuspid valve repair (208), left atrium ablation (145) and persistent foramen ovale or atrial septum defect (ASD) closure (172). The aetiology was degenerative in 738 (73.8%) patients and functional in 101 patients (10.1%). A total of 900 patients received MV repair (90%), and 100 patients (10%) underwent MV replacement. Perioperative survival was 99.1%, and periprocedural success 93.5% with a periprocedural safety of 96.3%. Improvement in periprocedural safety attributed to the lower rates of postoperative low output (P = 0.025) and less reoperations for bleeding (P < 0.001). 3D visualization improved cross-clamp (P = 0.001) but not cardiopulmonary bypass times. The use of loops and preoperative CT scan both had no impact on periprocedural success or safety but improved cardiopulmonary bypass and cross-clamp times (both P < 0.001).

CONCLUSIONS

Increased surgical experience improves safety in MIMVS. Technical improvements are related to increased operative success and decreased operative times in patients undergoing MIMVS.

Aortic Root Dissection Due to an Automated Fastener Device

Minimally invasive aortic valve replacement through a right thoracotomy is frequently performed in patients with aortic valve disease. The Cor-Knot Device (LSI Solutions) is an automated fastener that secures valve sutures. This case report is for a patient who developed postcardiotomy shock during a minimally invasive aortic valve surgery. The patient was found to have an aortic root dissection involving 90% of the aortic root circumference, including bilateral coronary ostia. The autopsy revealed that the aortic damage could be explained by a direct aortic intimal tear from the distal tip of the device shaft. The device was most likely not in perfect apposition to the sewing ring because of the restricted angle and space between the ribs.

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 &lt; 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 &lt; 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.

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®.

Incidence of valvular regurgitation and leaflet perforation by using automated titanium fasteners (CORKNOT®) in heart valve repair or replacement: less usual than reported

BACKGROUND

CORKNOT® facilitates a reduction in cardiopulmonary bypass (CPB) time, aortic cross clamp (ACC) time and operative time, but reported to be associated with other complications. We aim to quantify the incidence of valvular complications related to CORKNOT® and determine the feasibility of its use between different valvular surgeries.

METHODS

Patients who underwent heart valve repair or replacement surgery via the use of automated titanium suture fasteners (CORKNOT®) in a tertiary care hospital were included in the study. This single-centre retrospective study was conducted on 132 patients between January 2016 and June 2018.

RESULTS

In our study, the overall mean operative time was 320.0 ± 97.0 min, mean CPB time was 171.4 ± 76.0 min and the calculated mean ACC time was 105.9 ± 54.0 min. Fifty-eight patients (43.9%) underwent minimally invasive valve replacement or repair surgery and 66 patients (50.0%) underwent concomitant procedures. A total of 157 valves were operated on, with 112 (84.8%) single valve surgeries, 15 (11.4%) double valve surgeries and 5 (3.8%) triple valve surgeries. After reviewed by the cardiologist blinded towards the study, we report trivial and/or mild paravalvular leak (PVL) in immediate post-operative echocardiography was found in 1 (1.01%) patients. There were no reported cases of valvular thrombosis, leaflet perforation, device dislodgement or embolization, moderate and/or severe PVL during hospitalization and follow-up echocardiography within 1 year. Single mitral valve and aortic surgeries had comparable incidences of post surgical complications.

CONCLUSION

We conclude the feasibility of CORKNOT® utilisation in mitral and aortic valve surgeries. Additionally, incidence of CORKNOT® related complications in heart valve repair or replacement surgery is less usual in our setting than previously reported. These results motivate the use of CORKNOT® as a valid alternative with complete commitment.

Three-dimensional Video Assistance Improves Early Results in Minimally Invasive Mitral Valve Surgery

Compared with the mid-sternotomy approach, minimally invasive mitral valve surgery is usually associated with longer surgical times. The increasing use of new technology has facilitated this procedure and shortened its duration, which may further improve surgical results. Since 2004, 152 patients have undergone minimally invasive mitral valve repair. Video-assisted 2D technology was used for the first 112 patients, while video-assisted 3D technology was used for the remaining 40 patients. All patients were divided into three groups: group 1 - the first 50 patients (learning curve using 2D technology); group 2 - 62 patients (past the learning curve using 2D technology); and group 3 - 40 patients (3D technology). Mean patient age was 50 ± 12 years. There was no in-hospital mortality and no conversions to mid-sternotomy. Cardiopulmonary bypass and cross-clamp times were significantly shorter in group 3 compared with groups 2 and 1, respectively (108 ± 19 vs. 124 ± 22 vs. 139 ± 27, p < 0.001; and 76 ± 14 vs. 86 ± 18 vs. 97 ± 18, p < 0.001). Intraoperative echocardiography revealed higher freedom from more than mild residual mitral regurgitation after the first pump-run in group 3 compared to group 2 (97.5% vs. 90.3%, p = 0.04). Patients in the 3D group had less postoperative bleeding (p = 0.026) and a higher glomerular filtration rate before discharge (p < 0.001) compared with the 2D groups. No significant differences were observed in ventilation time (p = 0.066) and intensive care unit duration (p = 0.071). We concluded that in minimally invasive mitral valve repair, 3D video-assisted technology may provide shorter surgical times compared to 2D video-assisted technology.

Surgical effect and long-term clinical outcomes of robotic mitral valve replacement: 10-year follow-up study

BACKGROUND

To assess the safety and effectiveness, clinical experience with totally robotic mitral valve replacement (TE-MVR) for treating valvular heart disease was summarized and analyzed, and patients' recovery conditions were followed-up.

METHODS

The clinical data of 47 patients who received TE-MVR in our hospital between October 2008 and December 2015 were retrospectively analyzed. Among the patients, there are 26 men and 21 women. The mean age was 47.53±10.80 years. We followed up the transesophageal echocardiography (TTE) data of post-discharge patients and analyzed the operation results to determine the surgical effects of TE-MVR. The surgeries were mainly performed with the da Vinci Si robotic surgical system.

RESULTS

Thirty-five mechanical valves and twelve bioprosthetic valves were implanted. The cardiopulmonary bypass and aortic cross-clamping times were 122.02±25.45 min and 85.68±20.70 min, respectively. There was no operative mortality. The perioperative complication could only be found in one case, which was pleural effusion. All the TTE results were satisfying before discharge. No paravalvular leakage or prosthetic valve dysfunction was detected. All 47 patients were discharged successfully. During the long-term follow-up (28-110 months), 42 patients were followed-up (89.4%). Most of their heart function was NYHA class I and II. The postoperative TTE showed that the left atrial diameter and left ventricle diameter were decreased (P<0.01).

CONCLUSIONS

TE-MVR is reliable and effective, and the postoperative follow-up results revealed good heart function. Patients will obtain benefits from TE-MVR, such as small trauma and rapid recovery. Thus, it is a good minimally-invasive surgery of choice.

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.

A Rare Etiology for Bioprosthetic Aortic Valve Regurgitation

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COR-KNOT, an automatic knot fastener device can cause traumatic bioprosthetic valve perforation.

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Multiple eccentric jets in prosthetic valves is suspicious for valve perforation.

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Meticulous surgical techniques are essential to prevent this complication.

Inaugural experience and early results of minimally invasive approach in cardiac surgery in Auvergne region, France

Introduction: Minimally invasive approach in cardiac surgery has become an established and common technique in many cardiac surgery centres throughout the world. We report how we safely introduced minimally invasive approach in cardiac surgery in our department and we aim to demonstrate that this approach is feasible in any medium-size cardiac surgical centre.

Methods: it consisted of retrospective and descriptive study on 60 patients who underwent minimally invasive mitral valve (45) or aortic valve surgery (15) from January 2017 to Februry 2018. The approach was 3 to 6-cm right thoracotomy through the 4th and 5th intercostal space. The Cor-KnotTM system was used to tie the knots of the prosthesis in case of mitral valve replacement and aortic valve replacement and the ring if mitral valve repair.

Results: There was no conversion of thoracotomy to sternotomy. The average duration in ICU was 4.3± 2.3 days and 3.3 ± 1.5 respectively for mitral and aortic valve surgery. Four mitral patients and 1 aortic patient were reoperated for bleeding. No in-hospital death was observed. The postoperative discharge echocardiogram was normal in 95.6% of the mitral valve patients the trans-aortic mean gradient for the aortic valve patients was 16.3 ± 6 mm Hg. The thirty-day mortality was zero. In the majority of the patients, the scar of the thoracotomy were almost unseen.

Conclusion: It is possible to safely implement this new approach in any mid-size cardiac centers. The use of modern technology such as 3D video and Cor Knot allows achievement of excellent short term outcomes.

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.

Comparison of automated fastener device Cor-Knot versus manually-tied knot in minimally-invasive isolated aortic valve replacement surgery

BACKGROUND

The aim of our prospective study was to evaluate the efficacy and the safety of the Cor-Knot device in isolated aortic valve replacement by right anterior minithoracotomy.

METHODS

A single-center, prospective study was conducted between September 2009 and June 2018. Four hundred and forty patients were operated on for aortic valve replacement by right anterior minithoracotomy. Of these patients, 221 underwent isolated AVR surgery with stented prosthesis. Sutures were secured using the Cor-Knot titanium fastener in 63 patients (28.5%) and knots were hand-tied in 158 (71.5%). Statistical analyses were done using a propensity score with 1:1 matching for the automatically tied (AT) and manually tied (MT) patients.

RESULTS

The aortic cross-clamping and cardiopulmonary bypass times were significantly decreased in the AT group (74±13.8 minutes vs. 90.4±23.7 minutes, P<0.0001, and 100.8±20.6 minutes vs. 117.6±33.1 minutes, P<0.0001), compared with the MT group. Clinical outcomes were similar in the two groups, whether in the analysis of non-matched or matched groups. There was no difference in 30 day-mortality (1.2% vs. 0%, P=0.37), and the stroke and transient ischemic attack rates were comparable (2.5% vs. 1.6%; P=0.67). There was no significant increase in pacemaker implantation in the AT group (1.3% vs. 0%, P=0.36), and the rate of aortic regurgitation ≥ 2 was lower (3.9% vs. 0%; P=0.11) but not statistically significant.

CONCLUSIONS

The automated Cor-Knot fastener is an easy-to-use, time-saving device which does not increase perioperative morbidity and mortality in patients undergoing aortic valve replacement by right anterior minithoracotomy.

Use of an automated knot fastener shortens operative times in minimally invasive mitral valve repair

INTRODUCTION

Longer durations of cardiopulmonary bypass and aortic cross clamp are associated with increased morbidity and mortality. Little is known about the effect of automated knot fasteners (Cor-Knot®) in minimally invasive mitral valve repair on operative times and outcomes. The aim of this study was to evaluate whether these devices shortened cardiopulmonary bypass and aortic cross clamp times and whether this impacted on postoperative outcomes.

MATERIALS AND METHODS

All patients undergoing isolated minimally invasive mitral valve repair by a single surgeon between March 2011 and March 2016 were included (n = 108). Two cohorts were created based on the use (n = 52) or non-use (n = 56) of an automated knot fastener. Data concerning intraoperative variables and postoperative outcomes were collected and compared.

RESULTS

Preoperative demographics were well matched between groups with no significant difference in logistic Euroscore (manual vs automated: median 3.1, interquartile range, IQR, 2.1-5.5, vs 5.4, IQR 2.2-8.3; P = 0.07, respectively). Comparing manually tied knots to an automated fastener, cardiopulmonary bypass and aortic cross clamp times were significantly shorter in the automated group (cardiopulmonary bypass: median 200 minutes, IQR 180-227, vs 165 minutes (IQR 145-189 minutes), P < 0.001; aortic cross clamp 134 minutes (IQR 121-150 minutes) vs 111 minutes (IQR 91-137 minutes), P < 0.001, respectively). There was no mortality and no strokes, nor were there any differences in postoperative outcomes including reoperation for bleeding, renal failure, intensive care or hospital stay.

CONCLUSIONS

The use of an automated knot fastener significantly reduces cardiopulmonary bypass and aortic cross clamp times in minimally invasive mitral valve repair but this does not translate into an improved clinical outcome.

Minimally invasive surgical aortic valve replacement

Minimally invasive aortic valve replacement (MIAVR) is defined as a surgical aortic valve replacement which involves smaller chest incisions as opposed to full sternotomy. It is performed using cardiopulmonary bypass with cardiac arrest. It benefits from potential advantages of a less invasive procedure. To date, over 14 000 MIAVR have been reported in the literature. Due to heterogeneity of the studies, different surgical techniques and mainly the non-randomised nature of these studies comparing MIAVR with conventional aortic valve replacement, it is difficult to draw definitive conclusions. The two main techniques of MIAVR are mini-sternotomy and right anterior mini-thoracotomy. Both techniques with other less common forms of MIAVR will be discussed in this review. The advantages, disadvantages and surgical pitfalls will be discussed. Some of the advantages include shorter intensive care and hospital stay, reduced perioperative blood loss, less pain, improved respiratory function and cosmesis. The possible disadvantage of longer bypass and cross-clamp times may be counter balanced by the recent sutureless and rapid deployment valves. Despite some of the benefits, MIAVR has not been adopted by a significant proportion of the surgeons possibly related to the learning curve and requirements for re-training. As MIAVR becomes more common, randomised trials comparing this technique with transcatheter aortic valve implantation is warranted. In addition, assessing quality of life including return to work and functional capacity is needed.

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.

Automated fastener (Core-Knot) versus manually tied knots in patients undergoing aortic valve replacement: Impact on cross-clamp time and short-term echocardiographic results

The Core-Knot device is an automatic fastener used mainly in minimally invasive heart valve surgery procedures, to facilitate knot tying. The purpose of this report is to compare ischemic time and outcomes of surgical aortic valve replacements (SAVRs) utilizing the Core-Knot device compared with manually tied knots.Between January, 2014 and December, 2016, 119 patients underwent SAVR in Cape Cod Hospital. We compared patient's characteristics, cross-clamp time, and outcomes of 75 patients who underwent SAVR using Core-Knot to those of 44 operated using manually tied knots.Patient characteristics were similar between groups. Patients in the Core-Knot group had higher preoperative aortic valve area and higher ejection fraction. The use of Core-Knot was associated with reduced aortic cross-clamp time (median 70 vs 84 minutes; P < .001). Patients undergoing SAVR using Core-Knot were less likely to have postoperative aortic regurgitation (P < .001). Early mortality, and also the rates of early adverse events (including all cardiac, neurologic, and renal complications), and the immediate postprocedure echo findings were similar in the 2 groups. In multivariate analysis, the use of Core-Knot was associated with reduced postoperative mean gradient across the aortic valve and reduced occurrence of postoperative aortic regurgitation. Older age and larger valve size were other predictors of reduced postoperative mean gradients.The use of an automatic fastener (Core-Knot) in surgical aortic valve replacement cases reduce aortic cross-clamp time and help eliminate postoperative paravalvular aortic regurgitation.

Automated Titanium Fasteners Versus Hand-Tied Knots: A Randomized Controlled Trial

BACKGROUND

The relative benefits of automated titanium fasteners (LSI Solutions, Victor, NY) have not been examined in patients undergoing sternotomy. The aim of this study was to assess the time and cost required for suture fixation with the automated device versus conventional hand tying in sternotomy for mitral or tricuspid ring annuloplasty.

METHODS

Fifty patients scheduled to undergo primary mitral or tricuspid, or both, ring annuloplasty-based valve repair operation by a single surgeon were randomly assigned to receive either conventional hand-tied knots or automated titanium fasteners, with 25 patients in each group. The primary outcome variable was the time required to affix the annuloplasty device to the valve annulus.

RESULTS

The times taken to affix a mitral annuloplasty band or ring were 6.1 ± 0.9 min for manual tying versus 3.1 ± 0.4 min for automated fasteners (p < 0.0001); when calculated per annuloplasty stitch, the values were 22 ± 2 s versus 12 ± 1.1 s, respectively (p < 0.0001). The corresponding values for tricuspid annuloplasty were 4.2 ± 1.2 min (hand tying) versus 2.2 ± 0.3 min (automated fasteners) (p = 0.0005), and the times for each suture were 20 ± 2.1 s versus 13 ± 2 s, respectively (p = 0.0004). The use of the automated fastener had no significant impact on aortic cross-clamp time or cardiopulmonary bypass duration. Total cost associated with annuloplasty fixation with automated titanium fasteners (device cost in addition to operating room time cost) was significantly higher than with hand tying ($1,190 ± 374 vs $164 ± 60; p < 0.0001).

CONCLUSIONS

Using the automated fastener to facilitate annuloplasty fixation through a sternotomy resulted in a small procedural time savings (average of 10 s/stitch) that had no overall impact on cardiopulmonary bypass or cross-clamp times but added an average cost of $1,026 to the operation.

Use of an Automated Suture Fastening Device in Minimally Invasive Aortic Valve Replacement

BACKGROUND

Minimally invasive aortic valve replacement (mAVR) is gaining clinical acceptance; however, it is associated with increased operative times because of the limited surgical field and access. The Cor-Knot (CK; LSI Solutions, Victor, NY) is an automated fastening device designed to facilitate suture fastening, but clinical data in mAVR are lacking.

METHODS

From May 2014 to February 2017, 92 patients underwent mAVR at Spectrum Health in Grand Rapids, Michigan; 39 valves were secured with manually tied sutures, and 53 valves were entirely secured with the CK device. Preoperative characteristics and 30-day outcomes data were extracted from the local The Society of Thoracic Surgeons database and the patients' electronic medical records. Survival data were obtained from the Michigan State Social Security Death Index.

RESULTS

No significant differences in preoperative characteristics were noted between the two groups. Aortic cross-clamp time (72 ± 12 minutes vs 82 ± 15 minutes; p = 0.001) was significantly shorter with CK. There was no difference in the rate of postoperative mortality (0% vs 0%), stroke (0% vs 1.9%), atrial fibrillation (28% vs 33%), renal failure (0% vs 3.8%), or pacemaker implantation (5.1% vs 5.7%) between patients with manually tied sutures and patients with sutures fastened with the CK. Valve function on postoperative echocardiography and 1-year patient survival rates were similar.

CONCLUSIONS

In mAVR, the CK device was associated with reduced aortic cross-clamp time while providing equivalent clinical outcomes. Larger studies are needed to confirm the efficacy, safety, and cost-effectiveness of the CK device in minimally invasive aortic valve surgery.

Comparison of Automated Titanium Fasteners to Hand-Tied Knots in Open Aortic Valve Replacement

Objective

Aortic cross-clamp and cardiopulmonary bypass times are independent predictors of postoperative morbidity and mortality. Reducing ischemic times with automated titanium fasteners may improve surgical outcomes. This study compared operative times and costs of titanium fasteners versus hand-tied knots for prosthesis securement in open aortic valve replacement.

Methods

A randomized control trial was conducted during a 16-month period at a single university medical center. Patients undergoing elective aortic valve replacement were randomized to the titanium fastener (n = 37) or hand-tied groups (n = 36). Knotting, aortic cross-clamp, cardiopulmonary bypass, and total operating room times were recorded. Hospital charges were also calculated for these procedures.

Results

Baseline characteristics, concomitant procedures, prosthetic valve size, and sutures were similar between groups. The titanium fastener group had significantly reduced knotting (7.4 vs. 13.0 minutes, P < 0.001), aortic cross-clamp (69 vs. 90 minutes, P < 0.05), cardiopulmonary bypass (86 vs. 114 minutes, P < 0.05), and total operating room times (234 vs. 266 minutes, P < 0.05). Intraoperative complications occurred more frequently in the hand-tied group compared with the titanium fastener group. Postoperative complications were similar between groups. Operating room costs were significantly higher in the titanium fastener group (US $10,428 vs. US $9671, P = 0.01). Hospitalization costs did not differ significantly between the titanium fastener and hand-tied group (US $23,987 vs. US $21,068, P = 0.12).

Conclusions

Titanium fastener use was associated with shorter knotting, aortic cross-clamp, cardiopulmonary bypass, and operating room times and fewer intraoperative complications in open aortic valve replacement, without significantly increasing hospitalization cost.

Antegrade Cardioplegia Decannulation Using the Cor-Knot System in Minimally Invasive Mitral Valve Surgery

A right mini-thoracotomy approach may be used for mitral valve repair without compromising clinical outcomes. Compared with conventional sternotomy, there is an increased distance to the cardiac structures from the mini-thoracotomy incision, which makes certain technical acts more demanding. One particular challenge is hemostasis at the antegrade cardioplegia cannula site. We propose a novel technique to remove an antegrade cardioplegia cannula using the COR-KNOT system. This technique negates the need for tying with a knot pusher and reduces the risk of aortic injury and troublesome bleeding.

Valvular Regurgitation After Implantation of Prostheses Secured With Cor-Knot Automated Fasteners

Valvular regurgitation is a recognized complication of aortic and mitral valve procedures, with paravalvular leak the primary mechanism and transvalvular leak less common. The Cor-Knot automated fastener (LSI Solutions, Victor, NY) has been shown to be a safe, viable alternative to knot pushers or manual tying for use in these procedures. Here we present two patients in whom the orientation of the Cor-Knot fastener appeared to result in transvalvular regurgitation necessitating a redo operation. With adjunctive use of Cor-Knot devices, fastener orientation relative to valve geometry must be assessed for optimal results.