COMPARISON OF TWO SUTURE TECHNIQUES AND

MATERIALS: RELATIONSHIP TO PERIVALVULAR LEAKS

AFTER CARDIAC VALVE REPLACEMENT
CHRISTOPH BEDDERMANN, M.D. and HANS G. BORST, M.D.

Except for thromboembolism, perivalvular leaks are the most frequent

late complication after cardiac valve replacement. They occur in approximately 3-15% of all cases,"2'3 causing congestive heart failure and hemolytic anemia and necessitating reoperations associated with a high mortality.4'5 Periprosthetic leaks may result from endocarditis, calcification or other
abnormalities of annular tissue, pressure gradient and prosthetic resistance
to flow, or faulty implantation techniques. 3,6,7,8 This report describes a recent
2-year evaluation of two different suture techniques and materials and their
relationship to the development of perivalvular leaks.

MATERIALS AND METHODS

Excluding hospital mortality, 448 patients underwent 492 cardiac valve

replacements (Table I). Whereas 356 prostheses were implanted with approximately 16 Mersilene 2-0 sutures each, in an interrupted U-figure, 136
valves were implanted with 3 or 4 continuous Prolene 2-0 sutures according
to the technique described by Wada et al.9"0l"' The latter method was adopted
to reduce cardiopulmonary bypass and ischemic times. Personnel, valve models,
and quality of the annular tissue were essentially the same in the two groups.
Although both implantation methods were used with a similar frequency in
mitral valve replacement, continuous suturing was less frequently used in
aortic valve replacement.

RESULTS
Among the 492 cardiac valve replacements described above, 37 perivalvular leaks (7.5 %) were observed postoperatively. While the interrupted
Mersilene technique accounted for 5.1 % of the leaks, the continuous Prolene
suture technique resulted in nearly three times as many (14.0 %). There
was an approximately identical incidence of perivalvular leaks (5 %) in both
the aortic and mitral valve positions with the use of the interrupted suture
method. The continuous Prolene technique was associated with a periprosthetic leak incidence of 8.8 %7 in the mitral valve position and 21.4 % in
the aortic valve position. Thus, the continuous Prolene suture technique

From the Department of Surgery, Division of Thoracic and Cardiovascular Surgery,

Hannover Medical School, Hannover, Germany.
354

Cardiovascular Diseases, Bulletin of the Texas Heart Institute

Vol. 5
Number 4
December 1978

resulted in a threefold increase and, in aortic valve replacement, as much

as a fourfold increase in perivalvular leaks when compared with the standard method. The mean time interval before leak detection was 1 year for
those with interrupted sutures and less than 6 months with the continuous
suture implantation technique.
After a diagnosis of periprosthetic leak was established, patient management was determined by the severity of symptoms. Table II summarizes
the treatment of the 37 perivalvular leaks that occurred in our survey. Seven
reoperations were required to treat 18 leaks occurring after valve replacement with the interrupted Mersilene suture technique; most of these ruptures
were small and caused neither congestive failure nor hemolytic anemia. The
19 perivalvular leaks associated with the use of continuous Prolene sutures,
however, severely impaired ventricular function, and 13 valves had to be
re-explored. Thus, periprosthetic leaks associated with the continuous Prolene
suture technique required surgical repair twice as often as those observed
after valve replacement with the interrupted Mersilene suture technique.

TABLE 1. Distribution of Perivalvular Leaks After Cardiac Valve Replacement

Suture
Technique
& Material

Perivalvular
Leaks

No. of
Valves

Perivalvular
Leaks

Position

Interrupted
U Figure
2-0 Mersilene

356

18

( 5.1%)

201 aortic
155 mitral

10
8

( 5.0%)
( 5.2%)

Continuous
2-0 Prolene

136

19

(14.0%)

56 aortic
80 mitral

12
7

(21.4%)
( 8.8%)

TABLE I1. Management of Perivalvular Leaks After Cardiac Valve Replacement

Suture
Technique
& Material

Interrupted

Valve

Valve

Position

18

10 aortic
8 mitral

4
3

3
3

1
0

19

12 aortic
7 mitral

6
7

4
7

2
0

U Figure
2-0 Mersilene

Continuous
2-0 Prolene

No. Redo

Perivalvular
Leaks

Operations Replacement Refixation

355

At reoperation, no fractures of Mersilene suture were found, whereas four

fractures of continuous Prolene sutures were observed in the aortic valve
position and two in the mitral valve position (Fig. 1). In five mitral valve
replacements, valve dehiscence from the annular tissue was apparent, while
two aortic valves were found to be detached, with their Prolene sutures still
intact (Fig. 2).
Prosthesis replacement was required more often than refixation. Repair
of leaks, as well as repeat valve replacement, was performed with interrupted Mersilene sutures reinforced with Teflon pledgets when necessary.
There were no recurrent leaks. Two patients died, resulting in a hospital
mortality of 10%. Table III shows the types of prostheses associated with
reported leaks.

DISCUSSION
The problems encountered in connecting living tissue to a rigid artificial
material in the presence of disruptive forces suggest that it may be impossible

TABLE

Ill.

Types of Valves Causing Perivalvular Leaks

After Cardiac Valve Replacement

Suture
Technique
& Material

Aortic
Valves

Interrupted
U Figure
2-0 Mersilene

(n = 10)
LK 16x3
LK 18
LK 20x3
BS 23x2
BS 25

(n = 8)
SE 6550
SE 6320x2
LK
25x5

Continuous
2-0 Prolene

(n = 12)
LK 20
LK 22x2
LK 25x3
BS 25
BS 27x2
BS 29
BS 31x2

(n = 7)
LK 25x7

LK= Lillehei-Kaster
BS = Bjork-Shirley
SE = Starr-Edwards
Number (n) indicates size and/or model
356

Mitral
Valves

'O

...... ::%

.I:

Fig. 1 Dehiscence of mitral valve with broken Prolene suture.

Fig. 2 Dehiscence of aortic valve with intact Prolene suture.

357

to eliminate periprosthetic leaks completely. The suture method used for the
implantation of cardiac valves, however, may have a considerable influence
on the firmness and durability of such a union. Fixation of a cardiac valve
with interrupted sutures establishes a healing interspace between the annulus
and prosthesis,78 does not affect tissue between the individual sutures, and
may allow for at least minimal expansion of the annulus. Continuous suturing, on the other hand, produces uniform strangulation of tissue within the
suture line, especially in the presence of tension, and also prevents expansion
of the annulus. If the suture is not drawn tightly enough, however, it will
be subjected to excessive mechanical stress and fatigue-induced fracture,
which is most likely to occur with a monofilamentous material such as Prolene. Fracture of a continuous suture line will also cause extensive dehiscence,
amounting to V4 of the annular circumference in mitral valve replacement
and I/3 of the circumference in aortic valve replacement. Therefore, fracture
of a continuous suture line results in greater leakage and more severe symptoms than would result from the fracture of interrupted sutures.
The use of continuous sutures for prosthetic valve implantation has been
advocated by a number of authors.""'9"""0` Only two groups using continuous
Prolene suture techniques, however, have reported an increased incidence of
perivalvular leaks.8'12 In the two groups compared here, there was no significant difference in surgeons, valve models, or quality of the annular tissue. Therefore, the higher frequency of periprosthetic dehiscence and the
greater severity of symptoms in patients subjected to continuous suture implantation of both mitral and aortic valves must be related to the suture
method and/or the suture material used. A high incidence of periprosthetic
leaks may represent an unfortunate combination of annular tissue strangulation and the material fatigue propensity of Prolene. As a consequence of
our study, we abandoned the use of continuous sutures in cardiac valve
replacement, and the incidence of perivalvular leaks has declined to well
under 5 %.

SUMMARY
Between 1974 and 1976, the Division of Thoracic and Cardiovascular
Surgery of Hannover Medical School evaluated two different suture materials and techniques during 492 cardiac valve replacements in 448 patients.
While 356 prostheses (201 aortic/ 155 mitral) were implanted with an interrupted Mersilene 2-0 suture technique, 136 valves (56 aortic/80 mitral)
were replaced with continuous Prolene 2-0 sutures. Thirty-seven perivalvular
leaks resulted (7.5 o) - 5.1 %/ after implantation with interrupted Mersilene and 14.0 % after continuous suturing. In the aortic position, the continuous suture technique produced four times as many periprosthetic leaks
as did the standard method. Perivalvular leaks occurring after continuous
suture fixation required surgical repair twice as often as after the interrupted
suture technique. Twenty reoperations, resulting in a hospital mortality of
10%, were necessary to eliminate leakage.
358

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359