Mitral valve suturing technique. Needle grips of choice determined from a geometric basis

Placing sutures in the mitral annulus is often difficult due to its awkward anatomical location. The needle grips of choice were therefore determined by geometric analysis. The operating space model was restrictively designed so as to provide only narrow visualization of the uppermost portion of the annulus. The needle used was half-circled and 20 mm in length. The general rule of needle grips for addressing the needle on the annulus was as follows: those for the lower half of the annulus were grips holding the needle obliquely 30 degrees (oblique grip) at its midpoint, with ordinary suturing (advancing the needle by supination) for the cephalad half of the annulus and with the reversed grip (pronation) for the caudal half. For the lowermost portion, the choice was the reversed grip, obliqued 60 degrees and held near the swage. For the upper half, the choice was the grip holding the needle at its midpoint after rotation (rotated grip). However, the extent of rotation was 60 degrees for the uppermost portion, but 30 degrees for all others. This rule is useful as a general guide not only in the mitral annulus, but also in other operating fields where sutures can be placed in vertical tissues only through a narrow pass.