Antegrade Cardioplegia Decannulation Made Simple With the Cor-Knot System: Technique and Tips After 20 Consecutive and Controlled Patients

Introduction

Minimally invasive video-assisted cardiac surgery is a well-established and reproducible surgery. Although more complicated for the surgeon, it has been shown to be less traumatic for the patient and to provide faster recovery. One of the challenges in this setting is the knot tying. The Cor-Knot system is intended to overcome this difficulty and has already proven its efficacy in prosthetic valve and annuloplasty ring implantation. Hemostasis of the antegrade cardioplegia decannulation site on the ascending aorta can be technically demanding in minimally invasive approaches. We hypothesized that the Cor-Knot system can be used with a modification to reliably ensure hemostasis of the cardioplegia site.

The purpose of this study was to prospectively evaluate the effectiveness of this method in routine closing of the antegrade site and assess its security at midterm follow-up.

Case Series

This is a single-arm prospective study including 20 consecutive patients operated through a video-assisted method at our clinic between January 2019 and February 2019. The patients were operated for mitral valve repair alone or associated with tricuspid valve repair and atrial septal defect (ASD) closure. All patients underwent follow-up until October 2019. Individual patient consent was obtained.

Surgical Technique

The patient was approached through a small anterolateral thoracotomy and the entire procedure was accomplished under the vision of 30°, 10 mm video assistance. The detailed procedure has been described previously. ¹ A 2/0 Ethibond or 2/0 Ti-Cron braided, double-armed suture, passed twice through two Teflon-felt pledgets of 1 × 1 cm, was used for the aortic purse string. An aortic DLP cardioplegia cannula was inserted and the purse string secured around the cannula tip during the procedure. At the end of the procedure, after venting the left heart and under full flow cardiopulmonary bypass and an empty heart, a second purse string was inserted using 3/0 Prolene, passed through a tourniquet and tightened for security purpose. During this, the initial purse string was loosened and the cardioplegia cannula removed while the second purse string was tied down, closing the cannulation site. A Cor-Knot device was passed through and crimped on the Teflon-felt (Fig. 1). The two remaining tips of the Teflon-felt toward the right atrium were put together and tightened with a 5/0 Prolene suture in order to protect the sharp ends of the Cor-Knot (Supplemental Video). The second purse string was then tied down in the first 10 patients and taken off in the remaining 10 patients.

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Fig. 1

(a) After Cor-Knot deployment; (b) oversewing of the Teflon-felt pledgets around the metallic device; (c) result after oversewing; and (d) after tying down the second purse string.

Results

A total of 20 patients were included during the study period. Patient demographics and characteristics are detailed in Table 1. Hemostasis was achieved using the technique, with no requirement for further suture placement to ensure hemostasis of the cardioplegia cannulation site. The device was protected from the right atrial appendage, and there was no bleeding from this either.

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Table 1

Baseline Patient and Operative Characteristics.

Characteristic	Value
Patients	20
Male	15
Etiology of mitral valve regurgitation
Degenerative mitral valve disease	15 (75%)
Mitral and tricuspid valve regurgitation	3 (15%)
ASD	2 (10%)
Age (years)	53 ± 17
LVEF (%)	60 ± 3
Cross-clamp time (minutes)	106 ± 28
CPB time (minutes)	133 ± 30
Hospital stay (days)	5 ± 1.3

Abbreviations: ASD, atrial septal defect; CPB, cardiopulmonary bypass; LVEF, left ventricular ejection fraction.

All data are presented as mean ± standard deviation or number (percentage), unless otherwise noted.

All patients had follow-up at 6 months. During this time, no patients required a reoperation for aortic or right atrial erosion.

Discussion

We present an off-label use of the Cor-Knot device to ensure aortic cardioplegia cannulation site hemostasis. This device was designed to fix in place sutures placed through a valve or annuloplasty ring sewing cuff. This setting ensures that the hard metallic edges of the device are resting on the sewing cuff on its lower aspect and at a distance from any structures on the outer aspect, although erosions of aortic prosthetic valve leaflets have been reported. ²

Use of the Cor-Knot system for aortic cardioplegia site hemostasis was described in a series of 10 patients undergoing thoracotomy mitral valve repair. ³ The authors used a 2/0 Tevdek suture and not felt or other protection of the aorta and right atrium. There were no injuries linked to the system; however, no follow-up is provided.

In our modification, the Teflon-felt protected the aorta from erosion by the Cor-Knot clip. The hard metal tip of the Cor-Knot could be feared to erode the right atrium or atrial appendage, as it could rub against its metallic tip. To avoid this complication, the excess Teflon-felt is brought up on either side of the Cor-Knot metallic tip and tied together with a simple 5/0 Prolene. This maneuver avoids rubbing of the atrial tissue against the metal. This method is reproducible, quick, and appears safe in this initial experience, through non-rib-spreading video-assisted mini-thoracotomy.

Supplemental Material