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J Thorac Cardiovasc Surg 1996;111:286-287
© 1996 Mosby, Inc.

LETTERS TO THE EDITOR

Monofilament polypropylene sutures in aortic valve replacement

Division of Cardiothoracic Surgery, Department of
Surgery, Oulu
University Hospital
FIN-90220 Oulu, Finland

To the Editor:

We read with interest a recent article from Gott and associates ¹ reporting extremely low rates of thromboembolism after aortic root replacement. The authors speculated in their discussion section that the lower incidence of thromboembolism may have been related to the fact that the valve sutures, pledgets, knots, and much of the valve sewing ring are excluded from the bloodstream in a composite graft but remain exposed in isolated valve replacement. We agree with this statement and believe that suture material may increase the likelihood of morbid complications such as thromboembolism and prosthetic valve endocarditis (PVE) after cardiac operations. Despite major advances, such as the development of antimicrobial prophylaxis, better preoperative preparation of the skin, improved surgical techniques, early, aggressive treatment of wound infection, and prevention of low-output syndrome after operation, PVE continues to complicate the course of 2% to 4% of patients after cardiac valve replacement. ² We report here our experiences related to PVE after aortic valve replacement (AVR).

In the early phase of cardiac surgery at our hospital, polyfilament suture material was used in AVR. We analyzed the cases of a series of 283 patients operated on from 1972 to 1984. In this series, all prostheses basically had interrupted single sutures without pledgets. Eleven of the patients (4.1%) had infective PVE or periprosthetic leakage and had to undergo reoperation. At reoperation, swelling and untying of the polyfilament sutures and penetration of infection deeply into the aortic wall along the sutures, causing annular abscesses, were encountered. This experience led us to change the suture material, and since the mid-1980s we have routinely used 2-0 Prolene sutures (Ethicon, Inc., Somerville, N.J.) in all AVRs, inserting 30 to 40 interrupted single sutures without pledgets. We have now evaluated our 583 AVR operations from 1985 to 1994, and to date only one patient with infective PVE and periprosthetic leakage has needed reoperation, a rate of 0.1%.

The suture material used in cardiac valve replacements in general varies between monofilament and multifilament types. In a study on the effect of suture material on the development of vascular infection, 10⁵ Staphylococcus aureus bacteria were injected intravenously after aortotomy closure with various materials. ³ The study indicated that monofilament, nonabsorbable sutures were less likely to be associated with suture line infection. Polyfilament material was found to have a distinctly increased bacterial affinity relative to monofilament. ⁴ Our experience supports this finding. We conclude that single interrupted 2-0 Prolene sutures are a safe choice for AVR.

References

1. Gott VL, Gillinov M, Pyeritz RE, et al. Aortic root replacement: risk factor analysis of a seventeen-year experience with 270 patients. J THORAC CARDIOVASC SURG 1995;109:536-45
   
2. Rutledge R, Kim J, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1598 patients with mechanical and bioprosthetic valves. Arch Surg 1985;120:469-72.[Abstract/Free Full Text]
   
3. Dineen P. The effect of suture material on the development of vascular infections. Vasc Surg 1977;11:29-33.[Medline]
   
4. Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures: a possible factor in suture induced infection. Ann Surg 1981;194:35-41.[Medline]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tatu Juvonen Martti Lepojärvi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kärkölä, P. Articles by Salmela, E. Search for Related Content PubMed Articles by Kärkölä, P. Articles by Salmela, E.