Corresponding Author:
Sankalp P. Patel
Address: 311 9th St. N, Naples, FL 34102
Ph: (239) 624-0940
Fax: (239) 624-0941
Email: Sankalp.Patel@nchmd.org
Twitter: @SankalpPatelDO
Abstract : The implementation of automatic fasteners such as the Cor-knot® device (LSI Solutions, Inc.) has revolutionized the field of minimally invasive valvular surgery. Nonetheless, paravalvular regurgitation, valvular embolization, and early leaflet perforation are all potential complications which may occur. Late manifestations of leaflet perforation (>5-year post-implantation) are rare. Herein, we discuss a patient who underwent remote Trifecta® (St. Jude, Inc.) surgical aortic valve replacement (SAVR) presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot® sutures.
Introduction : Cor-knot® has facilitated a significant reduction in cardiopulmonary bypass and aortic cross-clamp times in comparison to manual hand-tied knots1. This has led to a revolutionary change in the discipline of minimally invasive valve surgery through mitigation of numerous bypass-related complications. The long-term complications of utilizing the automatic fastening device itself remain poorly understood, given most occur acutely. We describe a patient who underwent placement of a 23mm St. Jude Trifecta® aortic bioprosthesis, fastened with Cor-knot® sutures, presenting to our center 6 years later with severe, symptomatic bioprosthetic valvular regurgitation. The purported mechanism is secondary to leaflet erosion and consequential perforation due to the protruding automatically fastened metallic knots.
Case Report : A 70-year-old male (weight: 85kg, BMI: 28 kg/m2) with history of aortic stenosis underwent SAVR in 2015 at an outside hospital, 6 years prior to his presentation to our facility. He was noted to have no evidence of coronary disease and underwent successful implantation of a 23mm St. Jude Trifecta® bioprosthetic aortic valve at the outside center. Given use of a minimally invasive technique, the aortic prosthesis was secured with the Cor-knot® automatic fastening device. He presented to our institution in 2021, over 6 years after his initial SAVR, complaining of dyspnea on exertion which had worsened over the course of several weeks. His vital signs on arrival were significant for elevated blood pressure of 163/78 mmHg, revealing a widened pulse pressure. He underwent a two-dimensional transthoracic echocardiogram (TTE), revealing an LVEF (left ventricular ejection fraction) of 40-45%, mild to moderate mitral valve regurgitation, and an abnormally functioning bioprosthetic aortic valve. Dimensionless index via doppler interrogation was noted to be 0.34, however pressure half-time was noted to be less than 250 milliseconds, thus quantifying severe transvalvular aortic regurgitation. Given reduced LVEF, he underwent cardiac catheterization with unremarkable coronary occlusion noted. Subsequent transesophageal echocardiogram (TEE) was performed to elucidate true severity of bioprosthetic valve dysfunction and confirmed compromised severe transvalvular aortic insufficiency with revelation of a torn non-coronary leaflet (Video 1). Surgical removal of the malfunctioning bioprosthetic valve and redo-SAVR was planned the following day. The patient was brought to the operating suite in a fasted state and prepped and draped in usual sterile fashion. He was cannulated for cardiopulmonary bypass without complication. Re-do aortotomy was planned a quarter centimeter above prior aortotomy line with extension across the noncoronary sinus and coronary ostial cardioplegia was needed given severity of aortic insufficiency. Upon initial visual observation, decision was made to proceed with an aortic root enlargement to facilitate placement of a properly sized valve via a Manougian approach, which proceeded to occur in uncomplicated fashion. Exposure of the 23mm St. Jude Trifecta® aortic valve ensued in the interim, confirming suspicion on TEE. A large circular hole was observed in the left coronary leaflet and another large similar sized hole was seen in the noncoronary leaflet (Figure 1). Both holes corresponded to inward facing metallic Cor-knot®fastened knots, likely precipitating leaflet perforation. Uncomplicated valve resection followed thereafter along with completion of annular enlargement, with post-explant visualization of the St. Jude Trifecta® better unveiling the 2 separate perforations created in the left and non-coronary cusps, aligning with the position of metallic fastened knots (Figure 2A and 2B). A 23mm On-X® (CryoLife, Inc.) mechanical valve was implanted in the aortic position. After confirming successful valve placement, a bovine pericardial patch was utilized to close the aortotomy and routine weaning of bypass ensued followed by decannulation. The patient was brought back to our cardiovascular intensive care unit and follow-up echocardiogram showed a well-seated mechanical aortic valve without significant valvular or paravalvular regurgitation (Video 2).