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Suture Failure Causing Paravalvular Leak 20 Years after Mitral Valve Replacement

Cardiothoracic Surgery Department, Wythenshawe Hospital, Manchester M23 9LT, United Kingdom

Every surgeon has encountered problems with a ruptured suture while pulling or knotting, but late fracture of the sutures is an uncommon cause of complications in surgical practice. In the literature, these rare events have presented with varied complications such as false aneurysm in vascular surgery and failure of anchorage in orthopedic surgery.

In his medium term follow-up (eight years) of 435 patients who had primary mitral valve replacement; Dhasmana et al found only two cases of paravalvular leak due to fracture of continuous 2/0 polypropylene suture. There has been no report of coated braided polyester (CBP) suture failure in cardiac surgery. We encountered this in a 52-years-old female who had undergone triple valve replacement in 1980. The mitral valve had been replaced with a 29 mm Bjork-Shiley valve using continuous runs of 2/0 coated braided polyester sutures (Polydek-Genzyme). Twenty years later the patient presented with severe hemolytic anaemia caused by mitral paravalvular leak confirmed by transoesophageal echocardiogram. At the time of reoperation, there was a single suture fracture at the postero-medial aspect of the mitral annulus with no evidence of infection. In view of the frequent mechanical failure reported with the Bjork-Shiley valves, the valve was replaced with No. 29 St. Jude valve using pledgeted Ethibond 2/0 mattress sutures.

The cause of suture failure in this case is not very clear. CBP sutures are not subject to degradation or weakening by tissue enzymes, with no significant change in their tensile strength in vivo. Unlike Polypropylene and other suture materials, the strength, strain, and toughness of CBP remained stable after 6 weeks incubation in rats. The late fracture of the sutures may be the result of the fatigue characteristic of the suture material being subjected to cyclic loading. This phenomenon has been studied in vascular and orthopedic models in which repetitive, submaximal loading resulted in failure of both Polypropylene and CBP sutures. This seems to be the likely explanation for suture failure so many years after surgery in our case.

The early identification of this rare event and appropriate intervention has led to a successful recovery in our patient. Although this might be a rare and late morbid event, surgeons need to consider the long-term tensile strength in choosing suture material for valve surgery.

This Article Extract Full Text (PDF) 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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohamad N Bittar Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Khasati, N. H Articles by Deiranieya, A. K Search for Related Content PubMed PubMed Citation Articles by Khasati, N. H Articles by Deiranieya, A. K Related Collections Valve disease