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

Acute Clinical Adverse Outcomes Associated With the Cor-Knot

Background

Although an integral component of cardiac valve operations, manual knot tying has been linked with increased operative times and greater costs. The introduction of the Cor-Knot device (LSI Solutions) has eliminated hand-tied knots through an automatic titanium fastener system. However, adverse outcomes related to this device remain unknown. We thus used a nationally representative cohort to characterize adverse events of the Cor-Knot.

Methods

All adverse events for the Cor-Knot from 2015-2023 were tabulated from the Manufacturer and User Facility Device Experience database. Reports were screened to assess incident type and complication. Device and patient complications were categorized and reported as proportions to further ascertain factors contributing to the development of adverse incidents.

Results

Of an estimated 74 adverse events, the number of reported occurrences increased over the study period from 1 in 2015 to 13 in 2023. The greatest proportion of adverse events involved the Cor-Knot Mini (41.9%) or the Cor-Knot (37.4%), with malfunction representing the most frequent device incident (63.5%). Problems related to device usage (22.8%) or misfire (22.8%) constituted the most frequent complications after Cor-Knot usage. The most frequent complications included valve insufficiency (10.8%), presence of a foreign body (8.1%), or hemorrhage (2.7%).

Conclusions

Of all reported adverse events, malfunction was most likely to occur due to misfire or device usage issues. Patient complications comprised valve insufficiency, foreign body presence, or hemorrhage. As adoption and utilization of the Cor-Knot increases, future work is necessary to ensure adequate device training and minimize the incidence of adverse events.

MUTUAL: Towards Holistic Sensing and Inference in the Operating Room

Embodied AI (E-AI) in the form of intelligent surgical robotics and other agents is calling for data platforms to facilitate its development and deployment. In this work, we present a cross-platform multimodal data recording and streaming software, MUTUAL, successfully deployed on two clinical studies, along with its ROS 2 distributed adaptation, MUTUAL-ROS 2. We describe and compare the two implementations of MUTUAL through their recording performance under different settings. MUTUAL offers robust recording performance at target configurations for multiple modalities, including video, audio, and live expert commentary. While this recording performance is not matched by MUTUAL-ROS 2, we demonstrate its advantages related to real-time streaming capabilities for AI inference and more horizontal scalability, key aspects for E-AI systems in the operating room. Our findings demonstrate that the baseline MUTUAL is well-suited for data curation and offline analysis, whereas MUTUAL-ROS 2, should match the recording reliability of the baseline system under a fully distributed manner where modalities are handled independently by edge computing devices. These insights are critical for advancing the integration of E-AI in surgical practice, ensuring that data infrastructure can support both robust recording and real-time processing needs.

Safety and efficacy of the automated suture system in valvular heart surgery: a multicenter, prospective registry

BACKGROUND

In the last years, the Cor-Knot® device has been increasingly used in heart valve surgery. Our aim was to investigate the incidence of valvular complications in patients who underwent valvular surgery using the Cor-Knot® device in multicentric cohorts at one-year follow-up.

METHODS

Three hundred and sixty-eight patient underwent heart valve repair or replacement surgery using automated titanium suture fasteners in four cardiothoracic surgery departments between September 2018 and January 2020.

RESULTS

The mean age was 66.3±10.2 years. The mean Euroscore II was 3.14±5.65. Procedures were performed by right anterior mini-thoracotomy for 264 patients (71.7%) and by conventional sternotomy for 76 (20.7%). Isolated single valve surgery was most common (285 patients, 77.4%), 31 patients (8.4%) underwent isolated double valve surgery and 6 patients isolated triple valve surgery (1.6%). An associated procedure was performed in 46 patients (12.5%). Sixteen patients (4.3%) required permanent pacemaker implantation in the postoperative period. Eighteen patients died postoperatively (4.9%). Two patients had paravalvular leak ≥2 (0.5%). Mean follow-up was 14.7±7.1 months. Eight patients died during the follow-up (2.2%). Four patients had infectious endocarditis. The rate of valvular leak ≥2 was 1.5% and four patients underwent valve-related reoperation (1.2%), no reoperation was related to a valve lesion due to Cor-Knot®. There were three pacemaker implantation (0.9%) and 12 patients had NYHA>2 (3.7%). No case of metallic embolization, prosthesis thrombosis or leaflet perforation was reported during follow-up.

CONCLUSIONS

The use of the Cor-Knot® automated knotting system in valve surgery is not associated with an increase in the rate of paravalvular leakage, permanent pacemaker implantation or mortality postoperatively or during follow-up.

Automated titanium fastener for surgical aortic valve replacement-preventive role for infective endocarditis?

OBJECTIVES

Evidence on long-term clinical outcomes considering suture-securing techniques used for surgical aortic valve replacement is still uncertain.

METHODS

A total of 1405 patients who underwent surgical aortic valve replacement between January 2016 and December 2022 were included and grouped according to the suture-securing technique used (automated titanium fastener versus hand-tied knots). The occurrence of infective endocarditis during follow-up was set as the primary study end-point. As secondary study end-points, stroke, all-cause mortality and a composite outcome of either infective endocarditis, stroke, or all-cause mortality were assessed.

RESULTS

The automated titanium fastener was used in 829 (59%) patients, whereas the hand-knot tying technique was used in 576 (41%) patients. The multivariable proportional competing risk regression analysis showed a significantly lower risk of infective endocarditis during follow-up in the automated titanium fastener group (adjusted sub-hazard ratio 0.44, 95% confidence interval 0.20-0.94, P = 0.035). The automated titanium fastener group was not associated with an increased risk of mortality or attaining the composite outcome, respectively (adjusted hazard ratio 0.81, 95% confidence interval 0.60-1.09, P = 0.169; adjusted hazard ratio 0.82, 95% confidence interval 0.63-1.07, P = 0.152). This group was not associated with an increased risk of stroke (adjusted sub-hazard ratio 0.82, 95% confidence interval 0.47-1.45, P = 0.504). Also, a significantly lower rate of early-onset infective endocarditis was observed in the automated titanium fastener group, (0.4% vs 1.4%, P = 0.032).

CONCLUSIONS

Suture-securing with an automated titanium fastener device appears to be superior compared to the hand-knot tying technique in terms of lower risk of infective endocarditis.

Evaluation of a Novel Automated Suturing Technology for Mitral Chordal Implantation: 1-Year Results

PURPOSE

A new automated expanded polytetrafluoroethylene (ePTFE) suture placement device and a new customized titanium fastener deployment device were clinically evaluated in open and less-invasive mitral valve repair (MVr).

DESCRIPTION

Twelve patients were monitored for 1 year after undergoing MVr using the study devices. The study end points included surgical outcomes, operative times, valve repair durability, adverse events, and mortality.

EVALUATION

Three patients received 1 ePTFE chord using the study technology, and 9 patients received 2 chords. Mitral regurgitation at 30 days was absent in 8 patients, trace in 2, and mild in 2. At the 1-year follow-up, mitral regurgitation was absent in 7 patients, trace in 2, mild in 2, and moderate in 1. There were no replacement chord failures, reoperations, or death.

CONCLUSIONS

The initial outcomes of new automated ePTFE suture placement and titanium fastener deployment devices encourage further clinical evaluations.

A Rare Cause of Severe Bioprosthetic Transvalvular Regurgitation Diagnosed by Transesophageal Echocardiogram

•Suture snare of a strut may cause severe transvalvular MR after bioprosthetic MVR. •Intraoperative TEE is vital in evaluating hemodynamic instability in MVR surgery. •3D imaging improves the diagnosis of bioprosthetic dysfunction post-MVR.

Minimal Access Aortic Valve Surgery

Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable costs, and some benefits regarding hospital length of stay. The competing efforts of transcatheter aortic valve implantation for these same outcomes have provided an excellent range of treatment options for patients from cardiology teams. We describe the current state of the art, including technical considerations, caveats, and complications of minimal access aortic surgery and predict future directions in this space.

Prosthetic valve leaflet perforation resulting in critical aortic insufficiency: A rare late complication after use of Cor-knot®

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 postimplantation) are rare. Herein, we discuss a patient who underwent remote Trifecta® (St. Jude, Inc.) surgical aortic valve replacement presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot® sutures.

Eligibility for minithoracotomy aortic valve replacement: from Van Praet classification to complex scanner measurements

Van Praet proposed a classification to predict the ease of minithoracotomy aortic valve replacement (MT-AVR) based on the position of the aorta in the thorax. We have evaluated the relevance of complex computed tomography (CT) scan measurements to predict the ease of performing a MT-AVR. The first 57 patients who underwent MT-AVR from February 2018 to June 2020 were selected prior to surgery using Van Praet's IA and IB classes. We made additional measurements on aorta position related to the chest and the incision on the preoperative CT scan. The main objective was to correlate complex CT measurements with different operating durations. Van Praet criteria were significantly related to the distance from the center of the aorta to the midline (p value < 0.001), the distance from the center of the aortic ring to the midline (p value = 0.013) and aorto-sternal angle (p < 0.001). We did not find a correlation between CT criteria and the different surgical steps durations in patients belonging to Van Praet classes IA and IB. Our cohort of Van Praet class Ia and Ib patients were able to benefit from a MT-AVR without the need for conversion. Complex CT measurements do not provide additional information to predict surgical difficulties. This classification appears to be sufficient to determine a patient's eligibility for MT-AVR, even for a surgeon experienced in sternotomy in his first MT-AVR.

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.