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Mitral Valve Replacement with a Bioprosthesis: Prevention of Suture Entanglement
SHORT COMMUNICATION
Short Communication
Mitral Valve Replacement with a Bioprosthesis: Prevention of Suture Entanglement Sachin Talwar, MCh, Raghunath Mohapatra, MS and Arkalgud Sampath Kumar, MCh ∗ Department of Cardiothoracic & Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India Available online 26 August 2005
A simple technique of prevention of suture entanglement in the struts of bioprosthesis during implantation in the mitral position is described. (Heart Lung and Circulation 2006;15:48–49) © 2005 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Mitral valve replacement; Bioprosthesis
Introduction
T
he Carpentier-Edwards PERIMOUNT mitral pericardial bioprosthesis (Edwards Lifesciences, Irvine, CA, USA) is a trileaflet valve comprised of bovine pericardium that has been preserved in buffered glutaraldehyde solution and is mounted on a flexible frame and sewing rim. Excellent long-term results have been reported.1 However, implantation in the mitral position is technically difficult and as with all stented bioprosthesis which have free struts, looping or catching of a suture around the struts is a distinct possibility and this can impair proper function of the valve, which is tolerated poorly by patients. To avoid this complication, a very simple technique is described.
Technique After opening the valve container the valve holder handle is inserted into the valve holder and turned clockwise till the nut on the holder tightens. As the nut is tightened the three stent posts retract towards the center of the valve. The handle is fully screwed until stop is felt. Care must be taken that both the handle and holder remain attached to the valve so that the stent posts are retracted. However, too much tightening should also be avoided to prevent the anchoring sutures from breaking off due to excessive tension. In our technique the valve is implanted into position by using 10 interrupted horizontal mattress 2-0 ethibond sutures passed from the sewing rim of the valve into the native mitral annulus. Each double arm suture is held ∗ Corresponding author. Tel.: +91 11 26588889; fax: +91 11 26588889.
E-mail address: asampath [email protected] (A.S. Kumar).
by a haemostat and all the sutures are kept tense by the first and second assistants. Three No. 1 silk threads are now taken. A right angle artery forceps is passed around three double arm sutures around each strut and used to grasp this silk thread (Fig. 1). In this way, one silk suture is around three double arm ethibond sutures near each strut. These silk sutures are held by separate artery forceps. The valve is now lowered gently into the mitral annulus by pulling the valve sutures and as this is being done, the silk sutures are pulled by gentle traction, thus moving the valve sutures away from the struts and preventing looping around the struts (Fig. 2). Once the valve is lowered into position, these silk sutures are removed after confirming that no suture is looped around the struts. The holder handle is now unscrewed and removed without loosening the nut but the holder is left attached to the valve. The valve sutures are now tied one after the other. After this is accomplished, the anchoring sutures that hold the holder to the valve are divided and the holder assembly is removed. The left ventricular cavity is filled with saline and checked for any mitral regurgitation. The left atrium is now closed and the operation completed after routine de-airing maneuvers. Intra-operative trans-esophageal echocardiography is used to confirm proper prosthesis function.
Comment We have found this technique very simple, effective and least time consuming in preventing looping of sutures around the struts of bioprostheses. The technique is also effective in situations where the valve holder and the handle assembly are disengaged from the valve
© 2005 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2005.06.012
Figure 1. A right angle artery forceps is passed around three double arm sutures around each strut and used to grasp the silk thread.
due to breaking of the anchoring sutures as a result of excessive tightening of the handle into the holder. In such a situation, the struts are no longer retracted inwards towards each other and are very liable to be entrapped by sutures when the valve is being lowered into position.
Talwar et al. MvR with bioprosthesis
49
Figure 2. The valve is being lowered into the mitral annulus by pulling the valve sutures (black arrows) and as this is being done, the silk sutures (white arrows) are pulled by traction, thus moving the valve sutures away from the struts.
Reference 1. Neville PH, Aupart MR, Diemont FF, Sirinelli AL, Lemoine EM, Marchand MA. Carpentier-Edwards pericardial bioprosthesis in aortic or mitral position: a 12-year experience. Ann Thorac Surg 1998;66:S143–7.
SHORT COMMUNICATION
Heart Lung and Circulation 2006;15:48–49
Short Communication
Mitral Valve Replacement with a Bioprosthesis: Prevention of Suture Entanglement Sachin Talwar, MCh, Raghunath Mohapatra, MS and Arkalgud Sampath Kumar, MCh ∗ Department of Cardiothoracic & Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India Available online 26 August 2005
A simple technique of prevention of suture entanglement in the struts of bioprosthesis during implantation in the mitral position is described. (Heart Lung and Circulation 2006;15:48–49) © 2005 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Mitral valve replacement; Bioprosthesis
Introduction
T
he Carpentier-Edwards PERIMOUNT mitral pericardial bioprosthesis (Edwards Lifesciences, Irvine, CA, USA) is a trileaflet valve comprised of bovine pericardium that has been preserved in buffered glutaraldehyde solution and is mounted on a flexible frame and sewing rim. Excellent long-term results have been reported.1 However, implantation in the mitral position is technically difficult and as with all stented bioprosthesis which have free struts, looping or catching of a suture around the struts is a distinct possibility and this can impair proper function of the valve, which is tolerated poorly by patients. To avoid this complication, a very simple technique is described.
Technique After opening the valve container the valve holder handle is inserted into the valve holder and turned clockwise till the nut on the holder tightens. As the nut is tightened the three stent posts retract towards the center of the valve. The handle is fully screwed until stop is felt. Care must be taken that both the handle and holder remain attached to the valve so that the stent posts are retracted. However, too much tightening should also be avoided to prevent the anchoring sutures from breaking off due to excessive tension. In our technique the valve is implanted into position by using 10 interrupted horizontal mattress 2-0 ethibond sutures passed from the sewing rim of the valve into the native mitral annulus. Each double arm suture is held ∗ Corresponding author. Tel.: +91 11 26588889; fax: +91 11 26588889.
E-mail address: asampath [email protected] (A.S. Kumar).
by a haemostat and all the sutures are kept tense by the first and second assistants. Three No. 1 silk threads are now taken. A right angle artery forceps is passed around three double arm sutures around each strut and used to grasp this silk thread (Fig. 1). In this way, one silk suture is around three double arm ethibond sutures near each strut. These silk sutures are held by separate artery forceps. The valve is now lowered gently into the mitral annulus by pulling the valve sutures and as this is being done, the silk sutures are pulled by gentle traction, thus moving the valve sutures away from the struts and preventing looping around the struts (Fig. 2). Once the valve is lowered into position, these silk sutures are removed after confirming that no suture is looped around the struts. The holder handle is now unscrewed and removed without loosening the nut but the holder is left attached to the valve. The valve sutures are now tied one after the other. After this is accomplished, the anchoring sutures that hold the holder to the valve are divided and the holder assembly is removed. The left ventricular cavity is filled with saline and checked for any mitral regurgitation. The left atrium is now closed and the operation completed after routine de-airing maneuvers. Intra-operative trans-esophageal echocardiography is used to confirm proper prosthesis function.
Comment We have found this technique very simple, effective and least time consuming in preventing looping of sutures around the struts of bioprostheses. The technique is also effective in situations where the valve holder and the handle assembly are disengaged from the valve
© 2005 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2005.06.012
Figure 1. A right angle artery forceps is passed around three double arm sutures around each strut and used to grasp the silk thread.
due to breaking of the anchoring sutures as a result of excessive tightening of the handle into the holder. In such a situation, the struts are no longer retracted inwards towards each other and are very liable to be entrapped by sutures when the valve is being lowered into position.
Talwar et al. MvR with bioprosthesis
49
Figure 2. The valve is being lowered into the mitral annulus by pulling the valve sutures (black arrows) and as this is being done, the silk sutures (white arrows) are pulled by traction, thus moving the valve sutures away from the struts.
Reference 1. Neville PH, Aupart MR, Diemont FF, Sirinelli AL, Lemoine EM, Marchand MA. Carpentier-Edwards pericardial bioprosthesis in aortic or mitral position: a 12-year experience. Ann Thorac Surg 1998;66:S143–7.
SHORT COMMUNICATION
Heart Lung and Circulation 2006;15:48–49