Expanded Polytetrafluoroethylene for Chordal Replacement: Preventing Knot Failure

Purpose: Expanded polytetrafluoroethylene suture is commonly used for chordal replacement in mitral valve repair, but due to material characteristics, knots can unravel. Our aim was to determine the knot security, including how many throws are necessary to prevent knot failure, with Gore-Tex (W.L. Gore and Associates, Elkton, MD) and the newly available Chord-X (On-X Life Technologies Inc, Austin, TX).

Description: Knots were evaluated for maximal load based on: number of throws (6, 8, 10, and 12), tension to secure each throw (10%, 50%, and 85%) and suture type (Gore-Tex CV-5 and Chord-X 3-0). A physiologic force of 2 N was used for comparison.

Evaluation: We evaluated 240 knots. For all knots, the mean load to failure was 11.1 ± 5.8 N. Failure occurred due to unraveling in 141 knots (59%) at 7.1 ± 4.1 N and to breaking in 99 (41%) at 16.7 ± 2.0 N (p < 0.01). Gore-Tex failed at higher loads (12.6 ± 6.0 N vs 9.5 ± 5.2 N, p < 0.01); however, an equivalent number, 6 Gore-Tex and 6 Chord-X, unraveled at 2 N, all with fewer than 10 throws.

Conclusions: Expanded polytetrafluoroethylene has adequate strength to prevent breakage; however, a risk of knot unraveling at physiologic conditions exists when fewer than 10 throws are performed.