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\begin{document}

\title{Using Automated Suture Fastening System For Securing Aortic Cannulation
Sites In Minimally-Invasive Mitral Valve Surgery}



\author[1]{Abdullah Nasif}%
\author[1]{Saqib Masroor}%
\affil[1]{The University of Toledo Department of Surgery}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
Cor-Knot device is an automated suture fastening system which was
introduced to minimize the operating time during cardiac surgery. It is
currently being used for intracardiac suturing applications such as
implanting valves or rings during aortic and mitral valve surgery
primarily for shortening the procedure time. It also has higher holding
pressures and more consistent holding pressures than manual knots. We
describe here the use of Cor-Knot device in extracardiac suturing to
secure aortic root vent as well as aortic cannulation during minimally
invasive cardiac surgery. A 60-year-old male with mitral valve
endocarditis underwent minimally invasive mitral valve replacement via
right mini thoracotomy. Direct ascending aortic cannulation was
performed through a separate port. Cor-Knots were successfully used to
secure the purse-string sutures after decannulation at the end of the
case.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Cor-Knot (LSI Solutions, Victor, NY) is an automated suture fastening
system introduced in 2008 to eliminate manual knot-tying for valvular
prosthesis implantation. It also has higher and more consistent holding
pressures than manual knots, a quality that would make it a better
suturing system for high pressure sites such as aorta. However, aortic
root vents and aortic cannulas are typically secured with sutures that
are tied with 6 or more knots. During minimally invasive surgery, these
knots are tied outside the chest and then slid down on to the aorta.
There are instances when the aortic cannulation sites require additional
sutures to control residual leaks from an `air-knot'. There are also
instances of re-exploration for bleeding from these areas. Based on the
reports of better holding pressure, we have routinely used Cor-knots for
securing aortic root vent/antegrade cardioplegia catheter during
minimally invasive procedures for the past 4 years, without any
complications related to the suture or the fastener. Here we describe
the first reported case of using Cor-Knot for securing large-bore
cannula for direct aortic cannulation in minimally-invasive mitral valve
surgery.

\textbf{Methods and methods:}

Patient chart was reviewed for complete history and details of his
operative details and postoperative course. The Institutional Review
Board (IRB) approval was not obtained, since single case report with
deidentified data does not require IRB approval. The patient provided
informed written consent for the publication of the study data.

\textbf{Results:}

A 60-year-old male with enterococcus faecalis bacteremia, mitral valve
endocarditis, and very large mobile mass on the mitral valve underwent
minimally invasive mitral valve replacement with 29 mm Magna Ease
pericardial valve via right mini-thoracotomy (RMT). Due to severe
atherosclerosis in the iliofemoral vessels, direct aortic access was
needed through the chest. Two purse-string stitches were placed in the
standard fashion through the RMT incision and then pulled out of the
chest through a 12-mm port placed in the second intercostal space. Using
the Seldinger technique, a guidewire was introduced into the distal
ascending aorta within the pursestring via a needle placed through the
RMT. The wire was also pulled out through the port. After serial
dilation over the wire, a 20-French cannula was advanced into the aortic
arch and secured to the purse-string sutures. TEE confirmed the position
of the wire and cannula in the aortic arch. Cardiopulmonary bypass was
initiated and antegrade cardioplegia catheter was placed in the
ascending aorta. Surgery proceeded in the usual fashion. After excising
the infected valve, a 29 mm pericardial valve was implanted using
Cor-Knot device. After de-airing, aortic root vent was removed and the
site was secured with a Cor-Knot (Figure 1A and 1B). The patient was
weaned off cardiopulmonary bypass. Aortic cannula was removed and the
aortotomy purse-string sutures were secured separately with two
additional Cor-Knots through the port under vision (Figure 2). There was
no bleeding from the cannulation or the root vent site. Patient was
discharged from hospital in 15 days after undergoing femoral-to-femoral
bypass and iliofemoral endarterectomy for lower extremity ischemia on
post-op day 8.

\textbf{Discussion:}

Core-Knot has become popular in valvular surgery since its introduction
in 2009. While reducing cardiopulmonary bypass time is its prime
benefit, it has also been found to have better holding pressure than
manual knot tying.\textsuperscript{1} Lee et al. evaluated the strength,
consistency, and speed of prosthetic attachment sutures secured with
Cor-Knot and compared with those of manual knots.\textsuperscript{1}They
reported that suture holding pressures for the Cor-Knot fasteners were
significantly greater (median, 1008.9 vs 415.8 mm Hg, P \textless{}
0.001). Also, there was less variation in attachment pressures with
significant time savings occurred with the use of the Cor-Knot compared
with manual tying (12.4 vs 71.1 seconds per knot, P = 0.001). They
concluded that mitral annuloplasty ring sutures secured with the
Cor-Knot device were stronger, more consistent, and faster than with
manually tied knots.\textsuperscript{1}

One of the first reported studies on Cor-Knot system was conducted
between 2008-2010. Rodriguez et al. evaluated the clinical outcomes of
minimally invasive mitral valve surgery with prosthetic attachment
sutures secured by Cor-Knot system.\textsuperscript{2} No patient had
evidence of thrombus formation, hemolysis, or perivalvular
leaks.\textsuperscript{2} One instance of mitral ring dehiscence was
noted, but the dehiscence was due to a tear in the mitral annulus and
not associated with the titanium fasteners, which all remained
intact.\textsuperscript{2} They concluded that at a minimum of one-year
follow-up, Cor-Knot system is safe and effective for securing prosthetic
attachment suture.\textsuperscript{2}

Sazzad et al. quantified the incidence of valvular complications related
to Cor-Knot device.\textsuperscript{3} They reported trivial and/or mild
paravalvular leak (PVL) in immediate post-operative echocardiography and
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.\textsuperscript{3}

Lee et al. analyzed prosthetic fixation pressures in prosthetic aortic
valves, using Digital Pressure Mapping with 2D and 3D pressure maps
generated for all valves. None of the 288 Cor-Knot cases had any
decrease in intra-suture pressure, while 12 out of 144 manual-tying
cases that had pressure drop to less than 80 mmHg which is considered a
risk for paravalvular leaks (PVL) (P \textless{}
0.001).\textsuperscript{4} Therefore, it would be reasonable to use this
device at high pressure sites such as the aorta.

\textbf{Conclusion:}

Cor-Knot device is currently being used for intracardiac applications
such as implanting pericardial valve in minimally-invasive mitral valve
replacement. We have now utilized the Cor-Knot automated suture
fastening system to close small caliber sites in aorta, such as root
vents, instead of traditional suturing technique for over 4 years
without any suture site complications. In this report we have
demonstrated the safety of using this suture fastener system on large
bore aortic cannulation sites also. One of the benefits of using this
device is that it allows direct visualization of the site as the sutures
are being tightened. This should be considered for direct aortic
cannulation not only in minimally invasive but also open surgery where
this provides controlled deployment under direct vision, rather than
manual suturing with ``feeling'' the tightness of the knot by the
surgeon's hands.

\textbf{Author contribution statement:}

Abdullah Nasif: Data curation, Writing--original draft, Writing--review
\& editing, Visualization. Saqib Masroor: Conceptualization,
Investigation, Supervision, Validation, Writing--review \& editing.

\textbf{Figure/Video legend:}

Figure 1. A) Aortic root vent site secured with a Cor-Knot device. B)
Chest CT shows the clip on aortic vent site.

Figure 2. Chest CT shows the two clips on aortic cannulation site with
615 Hounsfield unit (HU) indicating high density material (Metal).

Video 1. Cor-Knot deployment at the aortic vent site.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Lee CY, Sauer JS, Gorea HR, Martellaro AJ, Knight PA. Comparison of
  strength, consistency, and speed of COR-KNOT versus manually hand-tied
  knots in an ex vivo minimally invasive model. Innovations (Phila).
  2014 Mar-Apr;9(2):111-6; discussion 116. PMID: 24755535.
\item
  Rodriguez R, Sutter FP, Samuels LE, Ice D, Morrissey S, Holzerman KM,
  Goldman S. Clinical Outcomes of Patients More Than One Year after
  Minimally Invasive Mitral Valve Repair and Replacement Surgery with
  Sutures Secured using Automated Titanium Fasteners. ISMICS. 2013 June
  12-15.
\item
  Sazzad F, Xian OZ, Ler A, Guohao C, Swee KG, Kofidis T. Incidence of
  valvular regurgitation and leaflet perforation by using automated
  titanium fasteners (CORKNOT\selectlanguage{ngerman}®) in heart valve repair or replacement:
  less usual than reported. J Cardiothorac Surg. 2021 Jun 7;16(1):163.
  PMID: 34099017; PMCID: PMC8186203.
\item
  Lee CY, Wong JK, Ross RE, Liu DC, Khabbaz KR, Martellaro AJ, Gorea HR,
  Sauer JS, Knight PA. Prosthetic Aortic Valve Fixation Study: 48
  Replacement Valves Analyzed Using Digital Pressure Mapping.
  Innovations (Phila). 2016 Sep/Oct;11(5):327-336. PMID: 27561176.
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/CorKnot---Figure-1A/CorKnot---Figure-1A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/CorKnot---Figure-1B/CorKnot---Figure-1B}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/CorKnot---Figure-2/CorKnot---Figure-2}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`CorKnot - Video 1.mp4`  available at \url{https://authorea.com/users/415675/articles/556110-using-automated-suture-fastening-system-for-securing-aortic-cannulation-sites-in-minimally-invasive-mitral-valve-surgery}

\selectlanguage{english}
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\end{document}

