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.