Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root

"Acute pseudo-pericardial tamponade": the compression of the thoracal inferior vena cava--a case report

We describe a case of 68-year-old woman which was admitted to our hospital for mitral valve replacement (MVR), in whom acute compression of the vena cava inferior developed after repair of lacerated atrio-caval junction with hemostatic tissue sealant, biologic glue (BioGlue, Cryolife, inc, Kennesaw, Ga). Removal of the BioGlue relieved the unexpected problem.

Nerve and Conduction Tissue Injury Caused by Contact with BioGlue

BACKGROUND

BioGlue-a surgical adhesive composed of bovine albumin and glutaraldehyde-is commonly used in cardiovascular operations. The objectives of this study were to determine whether BioGlue injures nerves and cardiac conduction tissues, and whether a water-soluble gel barrier protects against such injury.

MATERIALS AND METHODS

In 18 pigs, diaphragmatic excursion during direct phrenic nerve stimulation was measured at baseline and at 3 and 30 min after nerve exposure to albumin (n = 3), glutaraldehyde (n = 3), BioGlue (n = 6), or water-soluble gel followed by BioGlue (n = 6). Additionally, BioGlue was applied to the cavoatrial junction overlying the sinoatrial node (SAN), either alone (n = 12) or after application of gel (n = 6).

RESULTS

Mean diaphragmatic excursions in the BioGlue and glutaraldehyde groups were lower at 3 min and 30 min than in the albumin group (P < 0.05). Mean excursions in the gel group were similar to those of the albumin group (P = 0.9). Five BioGlue pigs (83%) and one gel pig (17%) had diaphragmatic paralysis by 30 min (P < 0.05 and P = 0.3 versus albumin, respectively). Coagulation necrosis extended into the myocardium at the cavoatrial junction in all 12 BioGlue pigs but only two gel pigs (33%, P < 0.01). Two BioGlue pigs (17%), but no gel pigs, had focal SAN degeneration and persistent bradycardia (P < 0.01).

CONCLUSIONS

BioGlue causes acute nerve injury and myocardial necrosis that can lead to SAN damage. A water-soluble gel barrier is protective.

Autologous glue: part of the sticky mystery unraveled

OBJECTIVE

The aim of the study was to evaluate the safety and efficacy of an autologous surgical tissue adhesive.

METHODS

Autologous glue was made out of canine concentrated plasma proteins mixed with 7.5% glutaraldehyde. Tensile strength and cytotoxicity of the autologous glue were tested. In a dog model, 8 transectioned iliac arteries were reanastomosed by using the animal's glue as the sole fixation method. After 120 days, all animals were angiographically controlled for patency and killed for histologic and immunohistochemical examination of the anastomosis.

RESULTS

The autologous glue showed sufficient tensile strength (557 +/- 135 N/mm2). The elasticity of the glue is influenced by variations of concentrations in both proteins and glutaraldehyde. Glutaraldehyde remained cytotoxic, even at low concentrations of 2.5%. All operative procedures were successful. Angiographs performed before animal death showed all but 1 vessel to be patent and showed manifest compression signs in 3 anastomoses. Histological examination revealed only a foreign-body reaction adjacent to the surface of the glue. The autologous glue does not trigger any immune response on immunochemistry. Because fibroblastic neo-endothelial lining was near to normal, potential glutaraldehyde leaching does not seem too harmful for the vascular juncture in the dog model.

CONCLUSIONS

Autologous glutaraldehyde glue has been used successfully as a vascular adhesive. In contrast to our previous studies with heterologous glue, we did not find a fierce acute inflammatory reaction indicating immune triggering. Nevertheless, glutaraldehyde remains a cytotoxic cross-linker. It is yet not known whether autologous glutaraldehyde glue can be used safely in clinical practice.

Use of Bovine Albumin-Glutaraldehyde Glue in Cardiovascular Surgery

As with any new surgical device, effectiveness requires both an understanding of its characteristics and proper technique of application. This report details application techniques from the author's experience for the use of bovine albumin-glutaraldehyde glue in a variety of cardiovascular surgical cases.

Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline

BACKGROUND

A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes.

METHODS

We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme.

RESULTS

Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions.

CONCLUSIONS

Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.

Influência da cola Bioglue® na deiscência de anastomose colônica: estudo experimental

A grande parte da morbimortalidade associada com a cirurgia colorretal, é associada com a deiscência anastomótica. Trabalhos experimentais sobre a utilidade de adesivos tissulares nas anastomoses colônicas são controversos, assim como estudos clínicos prospectivos randomizados são ausentes. O adesivo cirúrgico BioGlue®, formado por dois componentes - albumina sérica bovina purificada e glutaraldeído, forma uma ligação co-valente entre esses dois componentes e as proteínas teciduais no local de aplicação. O objetivo do estudo é avaliar a eficácia da BioGlue® na prevenção da deiscência anastomótica colônica em ratos. Foram utilizados 30 ratos machos da raça Wistar albino. A anastomose colocolônica foi confeccionada com sutura em pontos separados com polipropileno 5-0 (grupo 1) e aplicação da cola BioGlue® envolvendo a anastomose (grupo 2). Avaliaram-se a formação e extensão das aderências, a pressão de ruptura nas anastomoses e as alterações histológicas. Apenas um animal do grupo 1 (7%) faleceu, sendo constatada na necropsia, obstrução intestinal com grande distensão de alças. A mortalidade no grupo 2, por outro lado, foi de 10 animais (67%), sendo observado: distensão de alças intestinais, vazamento anastomótico e, em algumas situações, franca peritonite fecal por deiscência quase que total da anastomose. O presente trabalho nos permitiu concluir que, o uso da Bioglue® nas anastomoses colônicas realizadas em ratos, promoveu um aumento na morbimortalidade que foi estatisticamente significante comparado à sutura convencional.

Midterm Results of Aortic Repair Using a Fabric Neomedia and Fibrin Glue for Type A Acute Aortic Dissection

BACKGROUND

Controversy exists concerning the optimal surgical treatment of acute type A aortic dissection to reduce mortality rate and the need for reoperation. The goal of the present study was to evaluate midterm results of repair using a fabric and fibrin glue for acute type A aortic dissection.

METHODS

From 1994 to 2005, 100 patients with acute type A aortic dissection underwent supracommissural graft replacement using a fabric as "neomedia" and fibrin glue. Mean patient age was 65.7 +/- 11.3 years.

RESULTS

Hospital mortality was 9%. All 91 survivors underwent follow-up evaluation for a mean period of 47.7 months. Aortic regurgitation was restored to non or mild in 46 survivors who had preoperative aortic regurgitation in the immediate period, and only one patient developed moderate aortic regurgitation in the midterm period. Survival at 1, 5, and 10 years including hospital mortality was 89.0 +/- 3.1%, 75.2 +/- 5.1%, and 59.2 +/- 10.9%, respectively. Reoperation for aortic lesion was performed without mortality in three patients (residual dissection, n = 1; sinus of Valsalva dilatation, n = 1; acute redissection, n = 1). During two late reoperations, the fabric was observed to be firmly adherent to the dissected wall and maintained the shape of the aorta. Freedom from aortic reoperation was 98 +/- 2% and 98 +/- 2%, at 5 and 10 years, respectively.

CONCLUSIONS

Supracommissural aortic replacement using a fabric neomedia and fibrin glue resulted in low early and late mortality as well as a low reoperation rate.

Late Complications of Gelatin-Resorcin-Formalin Glue in the Repair of Acute Type A Aortic Dissection

BACKGROUND

During surgical treatment for acute type A aortic dissection, gelatin-resorcin-formalin glue is generally applied and its efficacy has been reported. However, some late complications that are potentially associated with this glue have also been reported. In the present study, we reviewed our experiences of treatment for acute type A aortic dissection and late complications that occurred in the anastomotic site, which needed a reoperation.

METHODS

From October 1994 to August 2005, 68 patients underwent emergency surgery for acute type A aortic dissection. Gelatin-resorcin-formalin glue was applied to 56 (82.4%) of these patients at one or both of the distal and proximal anastomosis sites.

RESULTS

Eight (11.8%) patients died in hospital within 30 days after the operation, among which two patients already had cerebral complications prior to the surgery. There were five late deaths from causes unrelated to cardiac events. Five patients developed an aortic pseudoaneurysm at the anastomotic site and underwent a late reoperation. All of these patients had been treated with gelatin-resorcin-formalin glue during the previous operation. Histologic examination of the resected aortic wall after the reoperation revealed tissue necrosis, severe local inflammation, and organization of old thrombi at the site of the glue application.

CONCLUSIONS

Late complications after the use of gelatin-resorcin-formalin glue may occur with a certain amount of risk, suggesting its toxicity for aortic tissue. Therefore, proper use of this glue and close follow-up of the patients are strictly required.

Aorto-right atrial fistula following acute type A aortic dissection repair

This report describes a rare case of aorto-right atrial fistula caused by rupture of a huge pseudoaneurysm that developed at the proximal aortic anastomotic site after total aortic arch replacement for acute type A aortic dissection. Preoperative aortography revealed that the fistula communicated with the right heart, but it was intraoperative Doppler transesophageal echocardiography that confirmed its course into the right atrium. Repeat total aortic arch replacement with concomitant direct closure of the fistula was performed successfully. The underlying cause of the pseudoaneurysm was the dehiscence of sutures at the proximal aortic anastomotic site, probably due to gelatin-resorcin-formaldehyde glue.

Late Results of Gelatin?Resorcin?Formalin Glue-aided Repair in Acute Type A Aortic Dissection

Gelatin-resorcin-formalin (GRF) glue has been used to obliterate the false lumen of dissected aortas, resulting in reduced mortality. However, because of the cytotoxicity of formalin, the application of GRF remains controversial. In this study, a total of 138 consecutive patients with acute type A dissection since 1995, who underwent emergency graft replacement, were reviewed. The mean age was 65.5 years. The hospital mortality rate was 6.5%. In-hospital re-exploration rate and patency rate of the false lumen were 6.5% and 24.7%, respectively. The actuarial survival rates were 81.5% after 5 years and 54.8% after 10 years. Reoperation-free rates were 87.9% after 5 years and 72.3% after 10 years. Tissue necrosis or aneurismal degeneration was not demonstrated at reoperation. In conclusion, GRF glue demonstrats excellent tissue adhesion and hemostasis capability, and contributes to improve surgical results.

Validity of a Limited Ascending and Hemiarch Replacement for Acute Type A Aortic Dissection

BACKGROUND

The extent of arch repair at emergency surgery for acute type A dissection is controversial. This study was designed to evaluate the rationale of tear-oriented conservative ascending/hemiarch replacement, comparing it against total arch replacement.

METHODS

A total of 134 consecutive patients with acute type A dissection who underwent emergency surgery between 1995 and 2005 were reviewed.

RESULTS

The median age was 68 years (range, 19 to 90); the patients were 62 men and 72 women. The extent of aortic resection included the ascending aorta and hemiarch in 105 patients (group AH) and the total aortic arch in 29 patients (group TA). The hospital mortality rates in groups AH and TA were 6.7% and 6.9%, respectively. The actuarial survival rates were 77.4% (AH) and 80.8% (TA) after 5 years, and 63.5% (AH) and 80.8% (TA) after 10 years. The freedom rates from reoperation were 91.3% (AH) and 88.0% (TA) after 5 years, and 60.9% (AH) and 76.6% (TA) after 10 years. Multivariate analysis indicated that predictors of reoperation were Marfan syndrome and aortic valve regurgitation.

CONCLUSIONS

Limited ascending/hemiarch replacement did not increase the risk of reoperation and would not compromise late results.

Use of BioGlue in Aortic Surgery: Proper Application Techniques and Results in 92 Patients

BACKGROUND

Surgery for pathology of the proximal aorta requires aortic wall reconstruction, re-approximation of the graft to native vessels, and potentially root replacement and valve resuspension or replacement. The purpose of this study is to describe proper application techniques and the results obtained with the adjunctive use of BioGlue Surgical Adhesive in this challenging patient population.

METHODS

Between August 1998 and June 2002, 92 consecutive patients underwent ascending/arch repairs, ascending/root repairs, Ross procedures, or ascending/arch repairs with a concomitant Ross procedure using BioGlue as an adjunct for anastomotic hemostasis.

RESULTS

Twenty-six patients (28.3%) in this series required no postoperative blood products. The mortality rate for this single-surgeon series was 3.3%. No device-related complications were observed. The incidence rate for postoperative pseudoaneurysm formation was 3.3%.

CONCLUSIONS

This series demonstrates the safety and effectiveness of BioGlue as a hemostatic adjunct in proximal aortic surgery. Use of the product helped to facilitate a minimal reliance on blood products and a low mortality rate.

Thoracic Aorta False Aneurysm: What Surgical Strategy Should Be Recommended?

BACKGROUND

Thoracic aorta false aneurysms (TAFA) are a surgical challenge. The best technical approach remains uncertain.

METHODS

Between 1981 and 2004, 57 patients underwent operation for TAFA (mean age 57 +/- 18 years; 43 [75%] were male). Symptoms included dyspnea 25 (44%), chest pain 22 (39%), and fever 18 (32%). Twelve (21%) were asymptomatic. Thirty-seven (65%) had undergone previous operation with a mean interval between operations of 80 +/- 90 months. Fifteen (26%) had a mycotic etiology. The TAFA involved the aortic root in 10 (18%), ascending aorta in 28 (49%), arch in 6 (11%), and descending aorta in 13 (32%). Twenty-one (37%) required femorofemoral cannulation and 28 (49%), circulatory arrest. Surgical techniques included graft replacement in 27 (47%), composite root in 10 (18%), patch repair in 10 (18%), and direct suture in 10 (18%).

RESULTS

Operative mortality was 7% (4 patients). Four of 32 (13%) had massive hemorrhage during redo sternotomy, and all of these had planned extramediastinal cannulation (all survived). Follow-up was 100% for 349 patient-years. Actuarial survival was 77% +/- 6%, 63% +/- 8%, and freedom from recurrent TAFA was 87% +/- 5% and 83% +/- 7%, at 5 and 10 years, respectively. Univariate analysis identified TAFA greater than 55 mm, urgent operation, and NewYork Heart Association functional class III or IV as predictors of hemorrhage during redo sternotomy. Obesity and ejection fraction of 35% or less were predictors of operative death.

CONCLUSIONS

Thoracic aorta false aneurysm symptoms may be minimal, and consequently a high degree of suspicion plus serial imaging is warranted. Extramediastinal cannulation, deep hypothermia, and circulatory arrest are required for large mediastinal TAFA. Despite serious risks, TAFA correction is possible with good long-term results.

Postoperative asystole in a vasculopathic man

We present a case of postoperative cardiac arrest caused by extrinsic occlusion of the right coronary artery by an aortic pseudoaneurysm. Extrinsic impingement upon the coronary arteries may result from several etiologies and lead to cardiac symptoms identical to those caused by intrinsic coronary disease. Extrinsic compression may be amenable to treatment with angioplasty or a combination of angioplasty and surgery.

Cerebrospinal Fluid Leak Rate after the Use of BioGlue in Translabyrinthine Vestibular Schwannoma Surgery: A Prospective Study

OBJECTIVE

To determine the effectiveness of BioGlue surgical adhesive in dural and middle ear closure after translabyrinthine vestibular schwannoma surgery.

STUDY DESIGN

A prospective study.

SETTING

Tertiary neurotological referral center.

PATIENTS

There were 24 patients in the BioGlue series. BioGlue was used in the same manner in all cases. All patients received similar postoperative care.

INTERVENTIONS

We studied the use of BioGlue and its possible effect on further reducing our department's cerebrospinal fluid leak rate for translabyrinthine vestibular schwannoma surgery.

MAIN OUTCOME MEASURES

Postoperative events were documented that enabled us to determine the overall cerebrospinal fluid leak rate (including incidence of various leak routes and morbidity).

RESULTS

The overall cerebrospinal fluid leak rate was 62.5% (15 of 24). Rhinorrhoea was the commonest route (80%), followed by postaural wound leak (33.3%) and external auditory canal otorrhoea (33.3%). Forty percent of cases had more than one cerebrospinal fluid leak route; 73.3% of leak cases required lumbar drain insertion, 40% needed pressure bandaging, and 66.7% had to undergo formal surgical repair. Forty percent had recurrent leaks after the initial episode had completely ceased. The mean extra stay in hospital as a result of the cerebrospinal fluid leak was 13.3 days.

CONCLUSION

Our preliminary prospective study of the use of BioGlue for dural and middle ear closure in translabyrinthine vestibular schwannoma surgery demonstrated poor results. The high cerebrospinal fluid leak rate associated with the unusual presentations and ensuing management difficulties in controlling these leaks lead us to recommend that BioGlue not be used in translabyrinthine vestibular schwannoma surgery. The manufacturers have noted our results and have considered adding our recommendation to the product data sheet.

Use of BioGlue Surgical Adhesive for Brow Fixation in Endoscopic Browplasty

OBJECTIVE

To determine the efficacy, longevity, and safety of BioGlue Surgical Adhesive for periosteal fixation in endoscopic browlifts.

METHODS

Retrospective review of 80 patients who underwent endoscopic browlift using BioGlue as the primary means of periosteal fixation. Visits were categorized as preoperative, 1 to 2 months, 3 to 6 months, and 7 to 12 months, and photographs of the first 15 patients were evaluated for change in brow position at each of these visits. Brow position was measured at the lowest brow hairs at the midpupillary and lateral canthus positions. Follow-up was 3 months to 3 years.

RESULTS

All of the first 15 patients were included in the 1- to 2-month postoperative grouping, 13 in the 3- to 6-month grouping, and 10 in the 7- to 12-month grouping. At all postoperative visits, brow elevation was significantly maintained during 12-month follow-up. Revision has been required in only 1 of 80 patients to date.

CONCLUSIONS

BioGlue is an effective and safe method of maintaining brow position in endoscopic browplasty. Brow elevation achieved using BioGlue was significantly maintained during the 7- to 12-month postoperative period. Tissue adhesives such as BioGlue have the potential to become significant adjuncts in facial plastic surgery and warrant more critical evaluation.

Late Complications Following Surgery for Type A Acute Aortic Dissection Using Gelatin-Resorcin-Formaldehyde Glue: Report of Two Cases

Gelatin-resorcin-formaldehyde (GRF) glue has been widely applied during operations for acute aortic dissection (AAD). At our institution, GRF glue was applied in 40 patients who underwent surgical procedures for AAD from 1995, two of whom needed a reoperation because of the development of a redissection and/or a pseudoaneurysm at the anastomotic sites. The operative findings and histological examinations suggested that the application of GRF glue during the initial operations might be related to the development of a redissection and/or a pseudoaneurysm.

Long-Term Effectiveness of Total Arch Replacement for Type A Aortic Dissection

BACKGROUND

With recent improvements in cerebral protection during aortic arch repair, total aortic arch replacement has become an accepted surgical method for acute type A aortic dissection involving the aortic arch. Our surgical strategy is to perform total arch replacement with a branched graft using antegrade selective cerebral perfusion for the patients with type A aortic dissection involving the aortic arch. The objective of this study is to evaluate the effectiveness of this strategy on late outcome.

METHODS

From October 1988 to April 2003, 46 patients underwent total arch replacement for acute type A dissection involving the aortic arch. Operations were performed with hypothermic cardiopulmonary bypass, antegrade selective cerebral perfusion during the arch repair, and open distal anastomosis.

RESULTS

Hospital mortality was 6.5% (3 patients), and permanent neurologic dysfunction was observed in 1 patient. During the follow-up period (mean, 5.4 years; range, 13 months to 15.6 years), 2 patients died, but the causes were not related to the aorta or aortic valve. Survival rates at 5 and 10 years postoperatively were 89.6% +/- 5.2% and 82.7% +/- 8.2%, respectively. Of the 41 survivors, 3 patients underwent successful reoperation for the distal thoracic aorta. Freedom from reoperation was 93.6% +/- 4.6% and 88.7% +/- 6.5% at 5 and 10 years, respectively. The residual false lumen in the thoracic aorta was frequently thrombosed (76.2%).

CONCLUSIONS

Total arch replacement for acute type A dissection may decrease the risk of late complications related to the false lumen and lead to excellent long-term survival.

Spontaneous Aortic Dissection in a 14-Year-Old Adolescent

We describe a case of a 14-year-old boy with a spontaneous aortic dissection. The diagnosis was suspected and confirmed with an urgent transthoracic echocardiogram and computer tomography (CT). He underwent an immediate surgery with tube graft replacement of the ascending aorta using a biological glue to reinforce the distal false lumen. Although the immediate postoperative course was uneventful, he continued to have a persistent distal false lumen, which was observed to be enlarging in size on close follow-up. Potential causes of this complication are discussed along with the various different etiologies for aortic dissection in this rare age group.

Operative Management of Ascending Aortic Dissections

Surgical management has been the established standard of care for acute ascending aortic dissection (Stanford type A or Debakey type I or II) with a worldwide average operative mortality rate of 23% compared with a 1-month mortality rate of 60% with medical management alone. Improving an institution's operative results depends on the establishment of a comprehensive and specialized team integrating their expertise into a protocol-driven system of care delivery specific for aortic dissections. The operative strategies and techniques for repairing aortic dissections should also be standardized within an institution to optimize outcomes. The primary goals of operative repair of ascending aortic dissection are to restore aortic valvular competency and systemic perfusion, to obliterate false-lumen blood flow, and to prevent rupture, myocardial infarction, stroke, and death. The goals, strategies, and expected outcomes for the operative management of acute ascending aortic dissection are presented.

Effective Use of Fibrin Glue for Acute Aortic Dissection

The use of gelatin-resorcine-formalin (GRF) glue for reconstruction of the vascular wall in the context of acute aortic dissection has become more common. However, anecdotal evidence suggests that use of the GRF glue results in higher rates of postoperative redissection. We describe an alternative method of reinforcing the dissected aorta with fibrin glue that may avoid this complication. A fabric sheet is presoaked in fibrinogen solution and then placed within the false lumen. Thrombin solution is then applied to the fabric sheet. That results in obliteration of the false lumen and effective reinforcement of the dissected wall.

Release of Glutaraldehyde From an Albumin-Glutaraldehyde Tissue Adhesive Causes Significant In Vitro and In Vivo Toxicity

BACKGROUND

A two-component sealant composed of bovine serum albumin and glutaraldehyde (BioGlue) is used to treat aortic dissections. Although glutaraldehyde guarantees strong adherence to tissues and synthetic materials, its toxic potential should be considered. The aim of this study was to determine the amount of glutaraldehyde released from BioGlue, its cytotoxic effects on cultured cells, and the local reaction of lung, liver, and aortic tissues to BioGlue.

METHODS

BioGlue was prepared according to the product insert, allowed to polymerize, and then overlaid with saline solution. The supernatant was analyzed for its content of glutaraldehyde. The cytotoxic effect of BioGlue was evaluated by adding the supernatants to either cultured human embryo fibroblasts (MRC5) or mouse myoblasts (C2C12). In vivo toxicity was assessed on three different tissues by applying BioGlue onto a partial lung resection, a liver abrasion, or an intact abdominal aorta in rabbits. Tissue samples were histologically evaluated 2 and 7 days after application.

RESULTS

Saline supernatants from polymerized BioGlue contained 100 to 200 mug/mL glutaraldehyde and were cytotoxic to both cell lines tested. Application of BioGlue to lung and liver tissue evoked serious adverse effects consisting of high-grade inflammation, edema, and toxic necrosis. Intact aortic tissue showed only low-grade or medium-grade inflammation.

CONCLUSIONS

Polymerized BioGlue releases amounts of glutaraldehyde that are capable of inducing cytotoxic effects both in vitro and in vivo. Use of BioGlue should be restricted to the aortic dissection procedure, as other tissues are sensitive to the amounts of glutaraldehyde released from the glue.

Persistence of Bioglue® in spinal dural repair

Bioglue is an organic surgical adhesive commonly used in vascular and cardiopulmonary repair surgery. It has been used in neurosurgical procedures to minimise the risk of cerebrospinal fluid leak. We report a case which demonstrates persistence of Bioglue at the repair site two years after its successful use in aiding dural closure after a lumbar decompressive procedure.

Composite Graft Replacement in Acute Aortic Dissection: Technique for Anastomosing the Right Coronary Artery without an Aortic Button

Acute aortic dissection that involves the ostium of the right coronary artery is a rare occurrence, but treatment by composite graft replacement of the aortic root is a technically difficult procedure, usually involving implantation of an aortic button. We describe 2 patients with ostium of the right coronary artery severely damaged by acute aortic dissection. In both cases we used a technique that mobilized the right coronary artery sufficiently so that it could be implanted without including an aortic button.

Type A acute aortic dissection: Immediate and mid-term results of emergency aortic replacement with the aid of gelatin resorcin formalin glue

BACKGROUND

The aim of this study was to assess the mid-term results of operation for type A acute aortic dissection with the aid of gelatin resorcin formalin glue.

METHODS

Emergency operation was carried out in 84 patients during the last 8 years. Fifty-five patients (65.5%) had mild-to-moderate aortic regurgitation. Gelatin resorcin formalin glue was applied to both the proximal and distal aortic stumps. We evaluated the presence of aortic regurgitation and the patency of the distal false lumen at the time of this study. The survival and reoperation-free rates were also assessed. In case of late reoperation, aortic wall samples of the glued area were examined histologically.

RESULTS

Ascending to hemiarch replacement were performed in 71 patients (84.5%). Total aortic arch and root replacement were required in 13 and 7 patients, respectively. Overall hospital mortality was 6.0% (5 patients). Late death was observed in 12 patients (14%). Reoperation for redissection in the aortic root, development of aortic regurgitation, and enlargement of the distal false lumen occurred in 1, 3, and 1 patient, respectively. Histologic examination showed no evidence of infiltration of inflammatory cells in the glued area. Computed tomography scan revealed a patent distal false lumen in 8 (14%) of 58 patients. Echocardiography detected moderate aortic regurgitation in 2 patients. The actuarial survival rate at 1, 5, and 8 years was 85.5%, 80%, and 60.0%, respectively. The reoperation-free rate at 8 years was 89%.

CONCLUSIONS

The results of emergency aortic replacement with gelatin resorcin formalin glue have shown reasonable early and late mortality and reoperation rates. There was no histologic evidence of adverse tissue reactivity by gelatin resorcin formalin glue.

Embolus of surgical adhesive to the extremities causing acute ischemia: Report of two cases

We present 2 cases in which a surgical adhesive embolized to the extremities. In the first case an adhesive was successfully used in the repair of a DeBakey type I aortic dissection. The patient was seen 2 months postoperatively with acute lower extremity ischemia, and a large piece of adhesive was extracted from the iliac and femoral arteries at embolectomy. In the second case the adhesive was used to seal a pericardial patch during repair of a ventricular septal defect. This patient was seen 1 day postoperatively with acute arm ischemia, and the adhesive particle was extracted from the brachial artery during embolectomy.

Bovine glue (BioGlue) is catabolized by enzymatic reaction in the vascular dog model

PURPOSE

The aim of the study is to explore the feasibility, patency, and histologic changes of a sutureless vascular anastomotic technique using biological glue as sole fixation method.

DESCRIPTION

Eight mongrel dogs (+/-15 kg) underwent direct reanastomosis of their transsected iliac arteries. Both ends were placed on a 5-mm balloon and the anastomosis was secured with biological glue (BioGlue, Cryolife, Kennesaw, GA). No intravascular suture material was used. All survivors were angiographically controlled for patency after 6 weeks and 3 months. Then the animals were euthanized and tissues were obtained for histologic and pathologic examination by light and electron microscopy.

EVALUATION

All procedures were successful except for 1 animal that died of uncontrollable bleeding at the anastomotic site. All first-time angiographically controlled grafts except three were patent. One animal showed manifest signs of fungal infection. Histology detected early granulocyte infiltration with an important enzymatic reaction adjacent to the surface of glue. Later on, the glue gradually regressed to disappear completely. Fibroblastic neointimal lining was noticed in most of the anastomoses, with some marked differences in the endothelium compared with normal.

CONCLUSIONS

Good permeability (57%) was observed in this new sutureless anastomotic technique in the canine model. In contrast to previous reported studies we noticed a clear enzymatic breakdown of the glue before total disappearance. It is not yet known to what extend use of the bovine glue was responsible for this phenomenon.

Application of biological glue in repair of intracardiac structural defects

BACKGROUND

BioGlue (Cryolife Inc, Kennesaw GA) was introduced as an alternative tissue sealant. Its most common application has been in repairs of acute dissections of the aorta. There is no reported experience with its use in the repair of intracardiac structural defects.

METHODS

In 5 patients BioGlue was used as an adjunct in repairs of complex intracardiac structural defects. It was used during patch repair of posterior mitral annular defects in 2 patients and aortic annular defect in 1 patient in the presence of active endocarditis. It was also used in 1 patient with a chronic atrioventricular groove pseudoaneurysm following mitral valve replacement, and in 1 patient during repair of a postinfarction posterior ventricular septal rupture.

RESULTS

There were no hospital or late deaths. Immediate intraoperative transesophageal echocardiography and late follow-up echocardiography documented complete and durable repair of all defects without recurrence. At follow-up all patients are in New York Heart Association class I-II, 6 to 29 months postoperatively. No patient has suffered late complications or exhibited signs of glue embolization.

CONCLUSIONS

BioGlue was found to be an effective adjuvant to the standard techniques used for the repair of intracardiac structural defects of various etiologies. Long-term follow-up is recommended to determine its long-term safety in this application.

Double-patch technique for postinfarction ventricular septal perforation

A modified infarct-exclusion technique for postinfarction ventricular septal perforation is presented. The perforation is closed directly by a small patch next to the conventional patch, and biological glue is applied between the patches to induce stable polymerization. The patch stuck to the infarcted septum, and no residual shunt was observed in any patient because the wide adhesion prevents excessive pressure on the suture line. Seven of 9 patients in whom this method was used had good results. This technique appears suited for repair of ventricular septal perforations, especially those with extensive fresh infarction.

A double patch sandwich technique for surgical repair of acute aortic dissection type A

BACKGROUND

This study compares two groups of patients with acute aortic dissection type A in whom two different techniques of anastomotic reinforcement were used, and evaluates the impact of these two techniques on perioperative blood loss and surgical outcome.

METHODS

One hundred eighty-five consecutive patients with acute aortic dissection type A between 1998 and 2002 were grouped according to the technique utilized for reinforcing the aortic anastomotic site. Group A consisted of 21 patients in whom a novel double patch sandwich technique was used, whereas in group B (164 patients) conventional Teflon felt strips served as reinforcement.

RESULTS

Preoperative profiles were comparable for both groups. Deep hypothermia and circulatory arrest were used in 180 patients (97%). Retrograde cerebral perfusion and retrograde cardioplegia were used in 70 patients (38%). Hospital mortality for the two groups was 4.7% (1 of 21) and 18% (29 out of 164), p < 0.30, respectively. On average 2 versus 6 U of PRBC (p < 0.21), and 3 versus 5 U of FFP (p < 0.004) were given during operation in groups A and B, respectively, and indicates reduced suture line bleeding in group A.

CONCLUSIONS

Modifications in the surgical technique for repair of acute aortic dissection type A, and in anastomotic reinforcement in particular, may lead to substantial reduction of suture line bleeding and diminished blood loss and transfusion requirements, and favorably affects patient outcome. Nevertheless, continued effort is mandatory to further enhance surgical outcome in this patient population.

Is extended aortic replacement in acute type A dissection justifiable?

BACKGROUND

The aim of this study was to evaluate the effectiveness of our surgical strategy for acute aortic dissection based on the extent of the dissection and the site of the entry, with special emphasis on resection of all dissected aortic segments if technically possible.

METHODS

Between January 1995 and March 2001, 43 consecutive patients underwent operations for acute aortic dissection. In all patients the distal repair was performed under circulatory arrest without the use of an aortic cross-clamp. Fifteen patients underwent aortic arch replacement with additional reconstruction of supra-aortic vessels in 3 patients. Complete replacement of all dissected tissue could be achieved in 21 patients (group 1). Because of the distal extent of the dissection beyond the aortic arch, replacement of all the dissected tissue was not possible in 22 patients (group 2).

RESULTS

Early mortality was 4.7% (2 patients), and the incidence of perioperative cerebrovascular events was 7.0% (3 patients). All of these events occurred in group 2 (p < 0.025). During the follow-up period of 6 years or less, 5 patients died, all from causes not related to the aorta or the aortic valve. A persisting patent false lumen was observed in 14 of the 36 surviving patients (39%).

CONCLUSIONS

Extended replacement of the dissected ascending aorta and aortic arch can be done with good early and midterm results, even though it requires a complex surgical technique. Therefore we advocate complete replacement of the dissected parts of the aorta in all patients in whom this is technically possible.

Aortopulmonary fistula after aortic root replacement

This report describes a rare case of aortopulmonary fistula in pseudoaneurysm of the left coronary ostial button. A 66-year-old woman suddenly developed congestive heart failure 3 years after aortic root replacement for acute type A aortic dissection. The diagnosis of aortopulmonary fistula was confirmed preoperatively by aortography, heart catheterization, and spiral computed tomography. She was discharged in good condition after surgical treatment. This serious complication should be considered in patients who have severe congestive heart failure after aortic root replacement.

A simple trick for repairing coronary pseudoaneurysm complicating a Bentall operation

Coronary pseudoaneurysms are a known complication of the Bentall wrap-inclusion method of composite valve grafting. We describe two cases to illustrate a straightforward technique for repair and prevention of coronary pseudoaneurysm formation.

Surgical outcome of acute type A aortic dissection: analysis of risk factors

BACKGROUND

The aim of this study was to assess the risk factors for the early and late outcome of the surgical treatment of acute type A aortic dissection.

METHODS

From 1983 to 2000, a total of 130 patients underwent operation for acute type A aortic dissection. Extent of distal aortic resection included ascending aorta in 19 patients (15%), hemiarch in 29 (22%), and total arch in 82 (63%). In all, 31 preoperative and perioperative variables were analyzed using univariate and multiple logistic regression models for independent predictors of in-hospital mortality and risk of late reoperation. After excluding in-hospital deaths, risk factors for late death were analyzed by Cox proportional hazard analysis.

RESULTS

In-hospital mortality was 19.2% (25 of 130 patients). Multivariable analysis indicated that renal/mesenteric ischemia and shock were independent predictors of in-hospital death. At 10 years, the actuarial survival rate including in-hospital mortality was 70.9% +/- 4.7%, and the reoperation event-free rate was 73.5% +/- 5.7%. Aortic valve resuspension was an independent predictor of proximal aortic reoperation, whereas nonresection of intimal tear and younger age were independent predictors for distal aortic reoperation. Chronic obstructive pulmonary disease was the only independent predictor for late death.

CONCLUSIONS

Patients' preoperative dissection-related complications and comorbidities significantly affect early and late survival rates after surgical treatment of acute type A aortic dissection.