A stitch in time saves nine: closing the hole after removal of the aortic root cannula

On completion of the surgical procedure the hole in the ascending aorta has to be closed after withdrawal of the aortic root cannula. The aorta is usually pinched by a double transversal stitch or it is crumpled by a purse string suture. Nevertheless, hemostasis is difficult to obtain because closure is done under recovered pressure. Additional stitches buttressed with teflon-felt pledgets are often required. Unfortunately, sensitivity to bacterial implantation and the proximity to the sternotomy line could make the foreign material of the pledgets responsible for chronic infections and fistulas.

Two simple square stitches orthogonal to each other could be a very useful suture combining simplicity with effectiveness. To do this, two 4-0 polypropylene half-threads are put obliquely through the full thickness of the aortic wall, to and fro with inverse obliquities. Each of them draws a cross inside the aortic wall and two sides of a square outside. As a result a little square is drawn by the threads around the hole.

For years we have never needed to reinforce the closure by supplemental stitches with hundreds of patients.

This type of closure has some advantages. In contrast to common stitches the aortic wall is not bent, crumpled or deformed, bites pass all aortic layers and the crossing of the threads covers the hole from inside rather than outside. Moreover, each thread can be tied with half of the tension required by other sutures because the two stitches act together but in the opposite direction. Finally, the technique is speedy and it requires only two half-threads. Most importantly, there is no need for teflon-felt pledgets. As a result, we have no longer seen any type of chronic infection or fistula.