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Novel knot-tying technique for mitral valve repair

2005; Elsevier BV; Volume: 129; Issue: 5 Linguagem: Inglês

10.1016/j.jtcvs.2004.09.026

1097-685X

Hironori Izutani, Masao Yoshitatsu, Jyun Kawamoto, Keijiro Katayama,

Cardiac Structural Anomalies and Repair

Mitral valve repair is a widely accepted procedure that now allows reconstruction in most patients with mitral regurgitation.1Okada Y. Nasu M. Takahashi Y. Handa N. Fujiwara H. Shinkai M. et al.Late results of mitral valve repair for mitral regurgitation.Jpn J Thorac Cardiovasc Surg. 2003; 51: 282-288Crossref PubMed Scopus (10) Google Scholar Techniques in repair, such as quadrangular resection, sliding plasty, annular plication, and annuloplasty, are well performed.2Rankin J.S. Orozco R.E. Addai T.R. Rodgers T.L. Tuttle R.H. Shaw L.K. et al.Several new considerations in mitral valve repair.J Heart Valve Dis. 2004; 13: 399-409PubMed Google Scholar Chordal reconstruction through placement of artificial chordae is also one of the techniques for repair of the prolapsed mitral leaflet to correct elongated chordae or replace ruptured chordae, causing mitral regurgitation.3David T.E. Omran A. Armstrong S. Sun Z. Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures.J Thorac Cardiovasc Surg. 1998; 115: 1279-1285Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar In placing artificial chordae, adjustment of chordal height is a key for successful mitral valve repair.4Adams D.H. Kadner A. Chen R.H. Artificial mitral valve chordae replacement made simple.Ann Thorac Surg. 2001; 71: 1377-1378Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Even the surgeon recognizes the optimal knotting position: overaggressive sliding of knots might happen when tying the suture because manual hand tying causes poor visualization of the knots as a result of the small and deep working place involved in the mitral valve procedure. We used a classical knot-tying device to avoid critical knot sliding and to obtain better visualization for the surgeon and the assistants in performing chordal reconstruction procedures. The device was developed by Dr Hideo Sakihara in 1935 at the former National Kure Hospital in Japan and was manufactured by Senko Medical Instrument Manufacturing Company (Tokyo, Japan).5Sakihara H. Sakihara-type deep vascular ligation apparatus.Surg Today. 1997; 27: 680-681Crossref PubMed Scopus (3) Google Scholar This device was initially designed for thoracic surgery, especially for operations of the hilar pulmonary vessels because of a deep and narrow surgical field. It has been used mostly in the fields of general surgery, gynecology, and thoracic surgery in Japan. This device is made of metal, and it can be simply autoclaved for regular reuse. The surgeon holds the device in one hand, makes a knot in the suture, pushes down the knot, and then pulls both ends of the suture with the other hand (Figure 1). The surgeon simply repeats the same maneuver and makes sure the knots are tightened. The surgeon and his or her assistants are able to see the tying process and make sure of the correct position of the knots at all times, even in a deep and narrow surgical field. Therefore, the use of this device makes the surgeon comfortable in deep knot tying. In our standard procedure for mitral valve repair requiring median sternotomy, left atriotomy was carried out after establishment of cardiopulmonary bypass and cardioplegic arrest. After exposing the mitral valve, chordal reconstruction was performed in the present case with anterior mitral valve leaflet prolapse (Figure 2, A). A pledget-supported double-needled CV-5 polytetrafluoroethylene suture (W. L. Gore & Associates, Inc, Flagstaff, Ariz) was placed on the anterolateral papillary muscle, and the suture was tied with the device. Then both ends of the suture were placed on the anterior leaflet (Figure 2, B) and tied with the same device to avoid sliding the knots (Figure 2, C). The position of the knots was well visualized during tying manipulation. After ring annuloplasty, the mitral valve repair was completed (Figure 2, D). This device has been used in Japan for many years but has not been introduced to other countries. It is not designed for endoscopic procedures. Therefore the device is not too long for direct vision surgery, unlike an endoscopic knot pusher, and can be simply autoclaved for regular reuse. The unique design of the distal tip securely holds knots when pushing down slip knots without having to thread the suture through the knot pusher. The device can be easily set on the suture or released from the suture to allow the surgeon to tie multiple knots quickly and simply. The surgeon simply needs to learn how to use one hand to hold the device and allow the other hand to maintain control of both suture strands at all times. It is sometimes difficult to tie a suture on the papillary muscle because of the deep and narrow surgical field present when performing artificial chordal replacement. Moreover, it is not easy to keep the optimal knot position on the suspended mitral valve leaflet during hand tying. The use of this device for chordal reconstruction is very reasonable because of its characteristics; however, there was no previous application in the field of cardiac surgery. Our experience showed that this device was suitable for not only tying deep sutures on the papillary muscle but also for accurate chordal height adjustment in artificial chordal replacement for mitral valve repair. Katayama, Kawamoto, Izutani, Yoshitatsu (left to right)