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).