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. 2018 Apr 7;45(2):121. doi: 10.14503/THIJ-18-6607

Continuous Suture Technique for Aortic Valve Replacement

Mi Kyung Lee 1, Jong Bum Choi 1, Nan Yeol Kim 1
PMCID: PMC5940282  PMID: 29844750

Continuous Suture Technique for Aortic Valve Replacement

To the Editor:

We read with interest the article by Kitamura and colleagues1 about their continuous suture technique for aortic valve replacement (AVR), which they concluded shortened cross-clamp time. However, continuous suturing is reported to have a higher incidence of paravalvular leak (PVL) in the long term.2

In our experience, most patients undergoing AVR by means of the continuous suture technique have had no significant problems.3 Occasionally, we have observed clinically insignificant PVL in the anterior commissure in some of these patients in the long term. Therefore, particularly in patients who have a thin aortic annulus, additional reinforcing sutures may be necessary at some weak suture sites. In the continuous suture technique, each stitch should hold sufficient annular tissue, such as in the simple interrupted-suture technique or pledgeted interrupted mattress-suture technique (pledgets on the aortic or ventricular side).4 We do not think that 6 stitches are enough to secure a prosthetic valve to the annulus. Moreover, 2-0 Prolene (Ethicon, a Johnson & Johnson company) seems as though it would be thick enough to damage annular tissue. We are familiar with the use of 3-0 Prolene suture and additional stitches (for example, 10 stitches per cusp).3,4

Using the continuous suture technique can shorten cross-clamp time in patients who have mild dilation of the sinotubular junction (STJ) and aortic sinuses. However, this technique might take more time during transverse aortotomy in patients who have a narrowed STJ and sinuses. In view of recent developments in cardiopulmonary bypass, we think that firmly placing the prosthetic valve in the annulus is more important than shortening cross-clamp time. Our main purpose when using the continuous suture or simple interrupted-suture technique for AVR is to form a smooth outflow tract with no remnant annular tissue inside the valve ring, and possibly a larger effective orifice area.5 The remaining 3 to 4 mm of valvular tissue is included in the annular sutures and serves as reinforcement between the valve suture ring and the annular tissue. The continuous suture technique for AVR may be safer and easier, especially in patients who have thick annular tissue and a dilated STJ.

References

  • 1. Kitamura T, Edwards J, Miyaji K.. Continuous suture technique for aortic valve replacement shortens cross-clamp and bypass times. Tex Heart Inst J 2017; 44 6: 390–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Nair SK, Bhatnagar G., Valencia O, Chandrasekaran V.. Effect of valve suture technique on incidence of paraprosthetic regurgitation and 10-year survival. Ann Thorac Surg 2010; 89 4: 1171–9. [DOI] [PubMed] [Google Scholar]
  • 3. Choi JB, Kim JH, Park HK, Kim KH, Kim MH, Kuh JH, Jo JK.. Aortic valve replacement using continuous suture technique in patients with aortic valve disease. Korean J Thorac Cardiovasc Surg 2013; 46 4: 249–55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4. Cha BK, Kim KH, Choi JB.. Effect of continuous suture technique for aortic and mitral valve replacement. Ann Thorac Surg 2015; 99 2: 747–8. [DOI] [PubMed] [Google Scholar]
  • 5. Tabata M, Shibayama K, Watanabe H, Sato Y, Fukui T, Takanashi S.. Simple interrupted suturing increases valve performance after aortic valve replacement with a small supra-annular bioprosthesis. J Thorac Cardiovasc Surg 2014; 147 1: 321–5. [DOI] [PubMed] [Google Scholar]
Tex Heart Inst J. 2018 Apr 7;45(2):121. doi: 10.14503/THIJ-18-6656

With response by

Tadashi Kitamura 1

The above letter was sent to Dr. Kitamura, who responds in this fashion:

I appreciate Choi and colleagues' interest in our paper.1 The main concern after using the continuous suture technique for aortic valve replacement (AVR) is paravalvular leak, which can occur anywhere along the leaflet attachment. Major risk factors for paravalvular leak are uneven stitching and improper suture tension.

To ensure equal stitching, it is helpful to mark the nadirs. When 5 stitches are placed in a leaflet, the 3rd stitch is placed at the nadir, which enables equal stitching. In our technique, we place 6 stitches to insert prosthetic valves ≥23 mm; however, in some cases, an odd number of stitches is better than an even number. Although placing additional stitches can compensate for uneven stitching, this action incurs more risk of suture loosening, cutting the tissue, or both. Therefore, minimal stitching is ideal.

In our technique, we use 2-0 polypropylene suture much as it is used in the classic continuous suture technique.2 We prevent loose sutures by securely tightening the suture ends before tying them. Using 3-0 suture is also acceptable; however, we bear in mind the tradeoff between using a thinner suture and the risks of breakage and cutting.

Tissue cutting tends to occur when suture bites are too deep or shallow. Because there is no reliable method to measure the thickness of annular tissue, we make suture bites 4 mm deep and use 17-mm half-circle needles. Equal and minimal stitching, even and adequate bites, and proper tightening of sutures can prevent tissue cutting.

When patients have a small sinotubular junction or small sinuses of Valsalva, the aortotomy should be extended toward the commissure between the left and noncoronary annuli or toward the noncoronary annulus, as the surgeon prefers. Traction sutures at each commissure enable a satisfactory surgical view so that continuous-suture AVR can be performed without trouble. Secure prosthesis placement is of utmost importance; however, if there is a choice of procedure, the one that minimizes cross-clamp time is best.

The use of sutureless valves might soon supersede surgical AVR; nevertheless, the continuous suture technique should remain valuable in various procedures, including aortic root replacement.

Footnotes

Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should generally contain no more than 6 references. They should be signed, with the exception that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.

References

  • 1. Kitamura T, Edwards J, Miyaji K.. Continuous suture technique for aortic valve replacement shortens cross-clamp and bypass times. Tex Heart Inst J 2017; 44 6: 390–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Doty DB. Aortic valve replacement. : Brown M, Baxter S, . Cardiac surgery: operative technique. St. Louis: Mosby Inc.; 1997. p 216–7. [Google Scholar]

Articles from Texas Heart Institute Journal are provided here courtesy of Texas Heart Institute

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