Discussion
Cor-Knot fastener is widely used in minimally invasive cardiac valve
surgery, but its use in aortic arch surgery has not been reported. In a
systematic review of Cor-Knot use in cardiac valve surgery, Jenkin et
al. conclude that significant evidence exists to show that Cor-Knot use
provides intraoperative advantages such as reduced intraoperative times
and increased knot strength and consistency4. However,
data is lacking as to whether these benefits translate to improved
postoperative outcomes5. Cor-Knot use in
sternotomy-based cardiac valve surgery was evaluated in a randomized
clinical trial and was determined to have no significant impact on CPB
or cross-clamp times but with an added financial
cost6. In another prospective observational study,
safety of Cor-Knot automated fastening in patients undergoing aortic
valve replacement was comparable to that of patients with manually tied
knots as demonstrated by similar 30-day mortality, stroke and transient
ischemic attack rates, pacemaker implantation rates, and rate of aortic
regurgitation7. These studies suggest Cor-Knot is
efficacious in minimally invasive cardiac valve procedures where there
is limited access and exposure, is safe particularly in aortic valve
replacement procedures, but may not provide clinical benefit in
sternotomy-based valve surgery. Cor-Knot automated fastener use in
aortic arch surgery with limited visualization has not been studied or
previously reported.
In this report, a patient with a personal history of connective tissue
disease and a prior open descending aortic repair for rupture presented
with the surgical emergency for ascending aortic pathology. We elected
to perform an aortic dissection repair, total arch debranching, and zone
3 aortic anastomosis. Given limited exposure from a sternotomy approach,
coupled patient specific characteristics including severe kyphosis and
COPD, we performed a zone 3 aortic replacement utilizing interrupted
pledgetted sutures and Cor-Knot fastener. We have employed this
technique in a series of subsequent cases with excellent success.
Potential pitfalls for this technique are iatrogenic coarctation, which
can be combatted by performing the anastomosis over an appropriately
sized Hegar dilator. While Cor-Knot utilization in minimally invasive
cardiac surgery is well described, to our knowledge this is the first
report describing its employment in open aortic surgery.