Ann Thorac Surg 1998;65:859-860
© 1998 The Society of Thoracic Surgeons
How to Do It
Semicontinuous Suture Technique for All Prosthetic Valve Insertions: The "Hoist" Technique
Patrick Ruchat, MD,
Michel Hurni, MD,
Adam P. Fischer, MD,
Hossein Sadeghi, MD
Department of Cardiovascular Surgery, University Hospital Center, Lausanne, Switzerland
Accepted for publication October 11, 1997.
Dr Ruchat, Service de Chirurgie Cardio-Vasculaire, Centre Hospitalier Universitaire Vaudois, rue du Bugnon 46, CH-1011 Lausanne, Switzerland (e-mail: medecins.ccv@hola.hospvd.ch).
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Abstract
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The semicontinuous suture technique as an alternative method in valve replacement is described. This specific technique is applicable for both adults and children requiring valvular prosthetic operations. This method combines advantages of the continuous and interrupted suture techniques.
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Introduction
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Since 1973 all cardiac valve prostheses have been inserted in our unit with the same technique (developed by Professor H. Sadeghi). We use an over-and-over semicontinuous suture with the valve prosthesis held above the native annulus. The prosthesis is secured with a "hoistlike" lowering technique. This method can be used in all situations encountered in valvular prosthetic operations for adults and children.
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Technique
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General
After excision of the native or prosthetic valve and thorough annulus decalcification, six double-armed initial sutures of 2-0 Prolene (Ethicon, Norderstedt, Germany) on a 26-mm taper-cut needle are used for the aortic and tricuspid procedure and eight sutures for the mitral valve.
Aortic Procedure
Six initial sutures, dividing evenly the annulus, are inserted at each commissure (Fig 1: A, C, E) and then directly in between (Fig 1: B, D, F). Beginning at the right commissure a continuous over-and-over suture runs from the ventricular side of the valvular annulus (point A), continuing into the sewing ring (point A') from the ventricular to the aortic side, and progresses clockwise every 3 mm along the cut edge up to the next initial suture (see Fig 1). The ends of each of the sutures are held by a mosquito forceps. At point B, the sutures continue all around the circumference.
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Aortic valve replacement. A transverse aortotomy is made, with the aortic cusps removed along the native annulus. Six initial double-armed sutures are placed. The first sixth of the circumference is completed.
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With a hoist method, the prosthesis is lowered onto the valve annulus by progressive gentle traction exerted sequentially on each end of the sutures. Countertraction is applied for uniform suture tension until the prosthesis is seated. The valve holder is then removed. A thorough inspection of the superior and inferior surfaces of the sewing cuff is made, checking for any free loops that could be removed by gentle traction on the related suture. Each suture is tied, leaving a final six knots (Fig 2).
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Aortic valve replacement. The sutures are tied, leaving six knots and a clear surface with a smooth transition from endothelium to prosthesis.
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Mitral Procedure
For the mitral valve procedure we recommend the use of eight initial sutures. Commencing in the middle of the posterior leaflet (point A), each continuous suture progresses clockwise up to the next initial suture, each one covering one-eighth of the sewing ring (Fig 3). After this the prosthesis is seated with the hoist method.
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Mitral valve replacement. A left atriotomy is made. Eight initial sutures are placed. When possible, we try to preserve the posterior leaflet, which is folded along the posterior annulus and secured with three 4-0 U-shaped stitches before being incorporated in the running suture.
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Tricuspid Procedure
Like in the aortic procedure, we recommend six initial sutures. Beginning at the posterior commissure, the suture progresses clockwise along the partially preserved septal leaflet avoiding injury to the conduction system. When seating the prosthesis, it is mandatory to first lower it along the triangle of Koch, therefore avoiding vigorous traction near the bundle of His.
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Comment
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Definition
We describe our method as a "semicontinuous" suture technique combining the advantages of both continuous and interrupted sutures. The prosthesis is held well above the valvular plane so that a clear view of the tissue annulus is obtained securing each stitch. It also avoids too many loops between the traction ends, allowing the prosthetic valve to be lowered onto the valve annulus with uniform suture tension. The procedure is shortened by less instrumental handling and fewer knots to tie, therefore reducing the cross-clamping time.
Universally Applicable
This method can be used in all types of valve prostheses. It is also suitable in the first row of sutures for the valvular homograft and stentless bioprosthesis. We use it in primary valve insertion and prosthetic valve replacement. This technique is also applicable after annulus repair or enlargement and in total aortic root replacement (Bentall procedure).
Perivalvular Leak
In the 354 consecutive St. Jude Medical valves we inserted between 1979 and 1984 [1], our overall rate of early periprosthetic leakage was 0.8%. These results are comparable with those of Dhasmana and colleagues [2], who use an interrupted technique and 1-0 suture material. They have shown in a single and multivariate analysis that periprosthetic leakage without infection was independent of the suture technique (interrupted versus continuous), but was dependent on the suture size and annular calcification. This demonstrates the importance of meticulous annular decalcification in our technique using a 2-0 suture.
Between 1976 and 1992, in 79 consecutive valve replacements for native valve endocarditis we detected on echocardiography five minor periprosthetic leaks (6.3%), all in the aortic position [3]. Because of the lack of significant clinical, hematologic, or hemodynamic disturbances, no reoperation was needed.
In a recent prospective, randomized study comparing the St. Jude Medical and the ATS Medical valve performed in our unit [4], Doppler echocardiography at the 3-month follow-up showed no periprosthetic leakage in 80 consecutive primary valve insertions.
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Acknowledgments
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This work is dedicated to Professor Hossein Sadeghi, Head of the Department from 1968 until 1995, for his contribution in promoting cardiac surgery in Switzerland.
The figures were prepared with the technical assistance of Mr Willy Guyot, CEMCAV-CHUV Lausanne.
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References
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- Debetaz LF, Ruchat P, Hurni M, et al. St. Jude Medical valve prosthesis: an analysis of long-term outcome and prognostic factors. J Thorac Cardiovasc Surg 1997;113:134-148.[Abstract/Free Full Text]
- Dhasmana JP, Blackstone EH, Kirklin JW, Kouchoukos NT Factors associated with periprosthetic leakage following primary mitral valve replacement: with special consideration of the suture technique. Ann Thorac Surg 1983;35:170-178.[Abstract]
- Dodge A, Hurni M, Ruchat P, et al. Surgery in native valve endocarditis: indications, results and risk factors. Eur J Cardiothorac Surg 1995;9:330-334.[Abstract]
- Karpuz H, Jeanrenaud X, Hurni M, et al. Doppler echocardiographic assessment of the new ATS Medical prosthetic valve in the aortic position. Am J Card Imaging 1996;10:254-260.[Medline]
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Abstract
Introduction
