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Antegrade Cardioplegia Decannulation Using the COR-KNOT System in Minimally Invasive Mitral Valve Surgery

Hashim, Sabet W. MD; Pang, Philip Y.K. MD

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: March/April 2017 - Volume 12 - Issue 2 - p 150–151
doi: 10.1097/IMI.0000000000000346
How-To-Do-It Articles

Abstract: 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.

From the *Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT USA; and †Department of Cardiothoracic Surgery, National Heart Centre, Singapore, Singapore.

Accepted for publication November 28, 2016.

A video clip is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.innovjournal.com).

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Philip Y.K. Pang, MD, Section of Cardiac Surgery, Yale University School of Medicine, 333 Cedar St, PO Box 208039, New Haven, CT 06520 USA. E-mail: philip.pang.y.k@nhcs.com.sg.

In patients with isolated mitral valve (MV) disease, a right mini-thoracotomy approach may be used for MV repair without compromising clinical outcomes.1 Our operative setup and approach are similar to that described by Jacobs and Sündermann.2 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. Persistent bleeding often occurs with knot-pusher tying, either from the loose suture or from tearing of the aortic wall. This bleeding requires additional sutures and may lead to troublesome persistent hemorrhage. Some surgeons have advocated the use of an endoaortic balloon, which does not require the insertion of a separate cardioplegia cannula, mainly to prevent such a complication of the antegrade cardioplegia decannulation.3 We have adopted a technique of decannulation that uses the COR-KNOT system (LSI Solutions, Victor, NY USA) to tie the suture. To achieve this purpose, a 2/0 Tevdek (Teleflex, Morrisville, NC USA) braided suture amenable to COR-KNOT tying is used in lieu of the commonly used 3/0 Tevdek suture that is too small for the COR-KNOT device.

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SURGICAL TECHNIQUE

At the conclusion of the procedure, the surgeon prepares to remove the cardioplegia cannula (Medtronic, Inc, Minneapolis, MN USA) by loosening the rubber tourniquet and 2/0 Tevdek purse-string, while the first assistant holds the cannula in place (Fig. 1B). The surgeon then loads the COR-KNOT device by passing both free ends of the purse-string suture through the open wire snare at the end of the shaft (Fig. 1C). The COR-KNOT device is advanced toward the aortic root cannula. In a coordinated manner, the first assistant removes the cardioplegia cannula (Fig. 2A), after which the surgeon deploys the COR-KNOT at the cannulation site while maintaining firm countertraction on the suture (Fig. 2B). Complete hemostasis at the cannulation site is achieved (Fig. 2C). The complete sequence of this technique is shown in Video 1, http://links.lww.com/INNOV/A113. In this case, the retractors were intentionally spread wider than usual for demonstrative purposes. This technique can also be applied through a smaller incision just large enough to permit the passage of the cardioplegia cannula and shaft of the COR-KNOT system.

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DISCUSSION

The introduction of an automatic knot fastener such as the COR-KNOT system has greatly facilitated minimally invasive valve surgery.4 In an ex vivo porcine MV annuloplasty model, mitral annuloplasty ring sutures secured with COR-KNOT were found to be stronger, more consistent, and faster compared with manually tied knots.5

The technique we describe provides the following advantages over the conventional approach.

1. The use of a knot pusher exerts an asymmetrical and variable force on the aorta, which may lead to bleeding or tearing of the aortic wall. In contrast, the COR-KNOT system exerts a symmetrical, consistent, and operator-independent force, which ensures complete hemostasis.

2. The speed, strength, and reproducibility of COR-KNOT fastened sutures are equivalent, if not superior to manually tied knots.

We advocate this decannulation technique for cases in which the COR-KNOT system has been used primarily for securing the mitral annuloplasty or valve sutures. Subsequent decannulation of the cardioplegia cannula may then be performed using a surplus COR-KNOT fastener, if available. When adopted in this manner, this technique does not incur any additional costs.

In summary, we present a new technique for removal of an antegrade cardioplegia cannula using the COR-KNOT system during minimally invasive MV surgery. We have not encountered any complications with this method in our series of 10 patients. This technique negates the need for tying with a knot pusher and reduces the risk of aortic injury and troublesome bleeding.

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REFERENCES

1. Goldstone AB, Atluri P, Szeto WY, et al. Minimally invasive approach provides at least equivalent results for surgical correction of mitral regurgitation: a propensity-matched comparison. J Thorac Cardiovasc Surg. 2013;145:748–756.
2. Jacobs S, Sündermann SH. Minimally invasive valve sparing mitral valve repair-the loop technique-how we do it. Ann Cardiothorac Surg. 2013;2:818–824.
3. Atluri P, Goldstone AB, Fox J, Szeto WY, Hargrove WC. Port access cardiac operations can be safely performed with either endoaortic balloon or Chitwood clamp. Ann Thorac Surg. 2014;98:1579–1583.
4. Grapow MT, Mytsyk M, Fassl J, et al. Automated fastener versus manually tied knots in minimally invasive mitral valve repair: impact on operation time and short- term results. J Cardiothorac Surg. 2015;10:146.
5. Lee CY, Sauer JS, Gorea HR, Martellaro AJ, Knight PA. Comparison of strength, consistency, and speed of COR-KNOT versus manually hand-tied knots in an ex vivo minimally invasive model. Innovations. 2014;9:111–116.
Keywords:

Minimally invasive cardiac surgery; Mitral valve repair; Antegrade cardioplegia; Suture fasteners

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©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery