Discussion:
The Cor-knot® device is an automated titanium suture
fastening device manufactured to knot and cut sutures throughout
minimally invasive valve surgeries in which manual ties may be
unfeasible. In addition to offering a convenient, expedited suturing
solution which decreases aortic cross-clamp and cardiopulmonary bypass
time, the Cor-knot® system has been shown to be just
as durable, if not more durable, than manually hand-tied
sutures2. Though shown to be a safe, viable
alternative to manual knot-tying, long-term complications of the
fastening device remain poorly understood. The St. Jude
Trifecta® aortic bioprosthesis was implemented in our
patient in 2015; recent data has demonstrated this valve has
necessitated reintervention more often than other
bioprostheses3. Whether the durability of the
Trifecta® valve contributed to the perfectly round
perforations in both leaflets is unable to be determined, but it can be
presumed that bioprosthetic valve deterioration may have had a role.
Severe transvalvular aortic regurgitation after implementation of a
Trifecta® (St. Jude, Inc.) prosthesis in conjunction
with the Cor-knot® has been scarcely reported. Several
reports exist demonstrating severe bioprosthetic transvalvular
regurgitation from a similar causative mechanism in other SAVR
prostheses, though the patients within these reports presented within 20
months of valve replacement4,5. As highlighted within
these reports, we believe the mechanism of leaflet failure in our
patient was due to repetitive trauma suffered by the leaflet as it
consistently flapped against the Cor-knot®.
Conclusion :
Our report serves to highlight an underreported and poorly understood
mechanism of bioprosthetic aortic regurgitation secondary to leaflet
trauma from an automated titanium fastening device. We recommend
operators to remain vigilant of this complication before utilizing
artificial knot-fastening systems and to orient knots away from imposing
neighboring leaflet impedance.