Automated Titanium Fasteners Versus Hand-Tied Knots: A Randomized Controlled Trial

Automated titanium fastener vs. hand-tied knots for prosthesis fixation in infective endocarditis

Objectives

To date, there is no evidence regarding the safety of automated titanium fastener compared with hand-tied knots for prosthesis fixation in infective endocarditis.

Methods

Between January 2016 and December 2022, a total of 220 patients requiring surgery for infective endocarditis were included in this retrospective analysis. The primary study endpoint was re-endocarditis during follow-up. The secondary study endpoints included stroke onset, all-cause mortality, and a composite outcome of either re-endocarditis, stroke, or all-cause mortality during follow-up.

Results

Suture-securing with an automated titanium fastener was performed in 114 (51.8%) patients, whereas the conventional technique of hand knot-tying was used in 106 (48.2%) patients. The risk of re-endocarditis was significantly lower in the automated titanium fastener group, as shown in a multivariable proportional competing risk regression model (adjusted sub-hazard ratio 0.33, 95% confidence interval 0.11-0.99, p = 0.048). The multivariable Cox proportional hazards regression analysis showed that the automated titanium fastener group was not associated with an increased risk of stroke-onset or attaining the composite outcome, respectively, (adjusted hazard ratio 0.54, 95% confidence interval 0.27-1.08, p = 0.082), (adjusted hazard ratio 0.65, 95% confidence interval 0.42-1.02, p = 0.061). Also, this group was not associated with an increased risk of all-cause mortality, as demonstrated in the multivariable Poisson regression analysis (adjusted incidence-rate ratio 1.42, 95% confidence interval 0.83-2.42, p = 0.202).

Conclusions

The use of automated titanium fastener device seems to be safe for infective endocarditis. Analyses of larger cohorts are required.

Cor-Knot automated fastener in distal anastomosis of total aortic arch replacement: A case report

Cor-Knot fastener use in sternotomy-based aortic arch procedures has not been reported. We present Cor-Knot fastener use over a Hegar dilator in an anatomically challenging total aortic arch replacement with no short-term and/or long-term complications.

Automated Suture Fastener Gaining Complete Commitment: Cumulative Propensity-Matched Comparison with Hand-Tied Knot in Heart Valve Surgery

OBJECTIVE

The COR-KNOT® device is an automated suture fastener in which there is currently no consensus on its role in heart valve surgery. Our aim was thus to conduct a one-to-one comparison of clinical outcomes with a hand-tied control cohort.

METHODS

We performed a single-center, cumulative propensity-matched retrospective cohort study on patients undergoing heart valve surgery from 1 January 2015 to 13 February 2020. Propensity score matching was performed on 693 patients, dividing them into matched COR-KNOT® (n = 124) and hand-tied (n = 124) groups.

RESULTS

Data on baseline demographics, operative details, and clinical outcomes were analyzed and compared between the groups. The patients in both the COR-KNOT® and control groups were well-matched. For the median sternotomy (MS) all procedures subgroup, use of COR-KNOT® was associated with a decrease of around 49 min in CPB time (220.00 [168.00 to 256.00] vs 70.50 [134.00 to 236.75] min, P = 0.006) and around 32 min in ACC time (145.00 [109.00 to 189.00] vs 112.50 [81.00 to 161.75] min, P = 0.008). In the MS valve and CABG subgroup, use of COR-KNOT® was associated with a 70 min reduction in overall operation time (401.00 [354.25 to 468.75] vs 330.50 [288.50 to 370.50] min, P = 0.013), 63 min reduction in CPB time (216.50 [191.75 to 283.25] vs 153.00 [124.75 to 207.50] min, P = 0.004) and 45 min reduction in ACC time (146.00 [134.50 to 205.50] vs 100.50 [71.50 to 150.75] min, P = 0.003).

CONCLUSIONS

In heart valve surgery, use of the automated suture fastener was associated with shorter CPB and ACC times. Additionally, we determined that clinical outcomes are most likely unaffected by the use of COR-KNOT®.

Incidence of valvular regurgitation and leaflet perforation by using automated titanium fasteners (CORKNOT®) in heart valve repair or replacement: less usual than reported

BACKGROUND

CORKNOT® facilitates a reduction in cardiopulmonary bypass (CPB) time, aortic cross clamp (ACC) time and operative time, but reported to be associated with other complications. We aim to quantify the incidence of valvular complications related to CORKNOT® and determine the feasibility of its use between different valvular surgeries.

METHODS

Patients who underwent heart valve repair or replacement surgery via the use of automated titanium suture fasteners (CORKNOT®) in a tertiary care hospital were included in the study. This single-centre retrospective study was conducted on 132 patients between January 2016 and June 2018.

RESULTS

In our study, the overall mean operative time was 320.0 ± 97.0 min, mean CPB time was 171.4 ± 76.0 min and the calculated mean ACC time was 105.9 ± 54.0 min. Fifty-eight patients (43.9%) underwent minimally invasive valve replacement or repair surgery and 66 patients (50.0%) underwent concomitant procedures. A total of 157 valves were operated on, with 112 (84.8%) single valve surgeries, 15 (11.4%) double valve surgeries and 5 (3.8%) triple valve surgeries. After reviewed by the cardiologist blinded towards the study, we report trivial and/or mild paravalvular leak (PVL) in immediate post-operative echocardiography was found in 1 (1.01%) patients. There were no reported cases of valvular thrombosis, leaflet perforation, device dislodgement or embolization, moderate and/or severe PVL during hospitalization and follow-up echocardiography within 1 year. Single mitral valve and aortic surgeries had comparable incidences of post surgical complications.

CONCLUSION

We conclude the feasibility of CORKNOT® utilisation in mitral and aortic valve surgeries. Additionally, incidence of CORKNOT® related complications in heart valve repair or replacement surgery is less usual in our setting than previously reported. These results motivate the use of CORKNOT® as a valid alternative with complete commitment.

Right Mini-Thoracotomy for Aortic Plus Mitral with or without Tricuspid Valve Surgery

OBJECTIVES

 Minimally invasive surgery is increasingly performed for isolated aortic or mitral valve procedures. However, combined minimally invasive aortic and mitral valve surgery is rare. We report our initial experience performing multiple valve procedures through a right-sided mini-thoracotomy (RMT) compared with sternotomy.

METHODS

 A total of 264 patients underwent aortic and mitral with or without tricuspid valve surgery through RMT (n = 25) or sternotomy (n = 239). Propensity score matching was used for outcome comparisons.

RESULTS

 Of the 264 patients, 25 (age: 72 ± 10 years; 72% male) underwent double (n = 19) and triple valve surgery (n = 6) through RMT and 239 (age: 71 ± 11 years; 54% male) underwent double (n = 176) and triple valve surgery (n = 63) through sternotomy. Sternotomy patients had more co-morbidities and preoperative risk factors (EuroSCORE II 10.25 ± 10.89 vs. RMT 3.58. ± 4.98; p < 0.001). RMT procedures were uneventful without intraoperative complications or conversions to sternotomy. After propensity score matching, surgical procedures were comparable between groups with a higher valve repair rate in RMT. Despite longer cardiopulmonary bypass times in RMT, there was no evidence for differences in 30-day mortality (RMT: n = 2 vs. sternotomy: n = 2) and there were no significant differences in other outcomes. During 5-year follow-up, reoperation was required in sternotomy patients only (n = 2). Follow-up echocardiography showed durable results after valve surgery. RMT patients showed higher survival probability compared with sternotomy, although this difference was not significant (hazard ratio = 0.33; 95% confidence interval: 0.06-1.65; p = 0.18).

CONCLUSION

 Combined aortic plus mitral with or without tricuspid valve surgery can safely be performed through a RMT with a trend toward better mid-term outcomes.

Automated Fastener vs Hand-tied Knots in Heart Valve Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Although several studies revealed that the Cor-knot automated fastener (LSI Solutions, Victor, NY) reduces aortic cross-clamp and cardiopulmonary bypass times, the influence of the device on postoperative morbidity and mortality still needs to be evaluated. The aim of this study was to verify the hypothesis that the use of the Cor-knot device for heart valve surgery reduces aortic cross-clamp and cardiopulmonary bypass times, and this time saving translates into reduced morbidity and mortality.

METHODS

Retrospective cohort studies and randomized controlled trials reporting on the use of the automated fastener vs hand-tied knots were reviewed. The following end points were compared: aortic cross-clamp and cardiopulmonary bypass times, postoperative valvular regurgitation, postoperative ejection fraction, prolonged ventilator support, renal failure, and mortality.

RESULTS

Eight studies reporting data on 942 patients were included in the final analysis. The Cor-knot device was associated with shorter cardiopulmonary bypass (mean difference [MD], -11.74; 95% confidence interval [CI], -14.54 to -8.93; P < .00001) and aortic cross-clamp times (MD, -14.36; 95% CI, -19.63 to -9.09; P < .00001) in minimally invasive heart valve procedures. Overall, lower rates of postoperative valvular regurgitation (risk ratio [RR], 0.40; 95% CI, 0.26 to 0.62; P < .0001) and prolonged ventilator support (RR, 0.29; 95% CI, 0.13 to 0.65; P = .003) were observed. No difference was observed in postoperative atrial fibrillation, ejection fraction, renal failure, and mortality.

CONCLUSIONS

The use of the Cor-knot device in heart valve surgery reduced aortic cross-clamp and cardiopulmonary bypass times. Furthermore, as compared with hand-tie methods, the automated fastener may lead to decreased rates of prolonged ventilator support and valvular regurgitation while being noninferior in terms of other postoperative outcomes and mortality.

What is the safety and efficacy of the use of automated fastener in heart valve surgery?

INTRODUCTION

Cor-Knot automated fastener has been used as an adjunct in heart valve surgery to eliminate the need for manual tying during valve implantation. Although reduced operative time and facilitation for minimally invasive surgery are clear benefits, whether their use translates to improved patient outcome remains debatable. This study aims to review the safety and efficacy of automated fasteners in heart valve surgeries.

METHOD

Specific searches were conducted via online medical databases (Pubmed, Embase, Ovid) between 1950 and June 2019. Longitudinal studies were included that provided operative parameters.

RESULTS

The initial literature search identified 3773 articles, but only eight met the inclusion criteria and were used for analysis: four studies related to aortic valve replacement (AVR), four related to mitral valve (MV) intervention (total n = 810). The meta-analysis revealed the significantly shorter aortic cross-clamp time in the Cor-knot group compared to manual tying, both in AVR and MV surgeries (P < .05). Cardiopulmonary bypass time was significantly shorter in the Cor-knot group when analyzing studies in MV surgery (weighted mean difference [WMD]: 110.0; 95% confidence interval: 12.3-207.7; P = .027) The use of Cor-Knot did not increase the risk of permanent pacemaker implantation, paravalvular leak, and 30-day mortality. The majority of studies reported no change in the length of intensive unit care and total hospital stay.

CONCLUSION

We confirmed that the majority of existing literatures indicated the safety and intraoperative efficacy with automated fastener application. Nevertheless, there is currently no evidence to support automated fastened sutures can translate its intraoperative advantages to improved patient outcome.