Prevention of residual ventricular septal defects with fibrin sealant

Strategies for blood conservation in pediatric cardiac surgery

Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery.

Valve selection in aortic valve endocarditis

Aortic prosthetic valve endocarditis (PVE) is a potentially life-threatening disease. Mortality and incidence of infective endocarditis have been reduced in the past 30 years. Medical treatment of aortic PVE may be successful in patients who have a prompt response after antibiotic treatment and who do not have prosthetic dysfunction. In advanced stages, antibiotic therapy alone is insufficient to control the disease, and surgical intervention is necessary. Surgical treatment may be lifesaving, but it is still associated with considerable morbidity and mortality. The aim of surgery is to perform a radical excision of all infected and necrotic tissue, reconstruction of the left ventricle outflow tract, and replacement of the aortic valve. There is no unanimous consensus on which is the optimal prosthesis to implant in this context, and several surgical techniques have been suggested. We aim to analyze the efficacy of the surgical treatment and discuss the issue of valve selection in patients with aortic valve endocarditis.

Fibrin, the preferred scaffold for cell transplantation after myocardial infarction? An old molecule with a new life

Fibrin is a topical haemostat, sealant and tissue glue, which consists of concentrated fibrinogen and thrombin. It has broad medical and research uses. Recently, several studies have shown that engineered patches comprising mixtures of biological or synthetic materials and progenitor cells showed therapeutic promise for regenerating damaged tissues. In that context, fibrin maintains cell adherence at the site of injury, where cells are required for tissue repair, and offers a nurturing environment that protects implanted cells without interfering with their expected benefit. Here we review the past, present and future uses of fibrin, with a focus on its use as a scaffold material for cardiac repair. Fibrin patches filled with regenerative cells can be placed over the scarring myocardium; this methodology avoids many of the drawbacks of conventional cell-infusion systems. Advantages of using fibrin also include extraction from the patient's blood, an easy readjustment and implantation procedure, increase in viability and early proliferation of delivered cells, and benefits even with the patch alone. In line with this, we discuss the numerous preclinical studies that have used fibrin-cell patches, the practical issues inherent in their generation, and the necessary process of scaling-up from animal models to patients. In the light of the data presented, fibrin stands out as a valuable biomaterial for delivering cells to damaged tissue and for promoting beneficial effects. However, before the fibrin scaffold can be translated from bench to bedside, many issues must be explored further, including suboptimal survival and limited migration of the implanted cells to underlying ischaemic myocardium. Copyright © 2016 John Wiley & Sons, Ltd.

Use of fibrin sealants in cardiovascular surgery: a systematic review

BACKGROUND

Fibrin sealants are used for hemostasis and tissue adherence.

AIM OF STUDY

This systematic review summarizes published clinical data for fibrin sealant use in cardiovascular surgery.

METHODS

A literature search for the following terms was conducted using PubMed and EMBASE: (TISSEEL or Tissucol or Beriplast P or Evicel or Quixil or Crosseal or Reliseal or Fibringluraas or Bolheal or Tachosil or Vivostat or Vitagel or Artiss or "fibrin glue" or "fibrin sealant" or "fibrin tissue adhesive") and (cardiac or cardiovascular or vascular or heart or coronary or surgery). Case reports and series were excluded; although reports of controlled trials were preferred, uncontrolled trial data were also considered.

RESULTS

Clinical trials and chart review analyses of fibrin sealants were identified and summarized. Although clinical trial data were available for other agents, the majority of published studies examined TISSEEL. Overall, TISSEEL and other fibrin sealants showed improvements over standard of care or control groups for a variety of predefined endpoints. Safety findings are also summarized.

CONCLUSIONS

Data from these studies showed that fibrin sealants were well tolerated and provided effective hemostasis in a range of cardiac and aortic surgeries.

Surgical closure of a perimembranous ventricular septum defect with a running suture

A ventricular septum defect (VSD) is a common defect in congenital surgery, either isolated or associated with other malformations. Most of the defects are located around the membranous septum and hence are called 'perimembranous'. The less damaging approach to close them is certainly through an incision in the right atrium. In some trunco-arterial malformation, an incision in the infundibulum is necessary to connect the right ventricle to the pulmonary arteries. A perimembranous VSD can then also be closed using the same incision. The videos show the closure of a perimembranous VSD using these two common approaches. Although many surgeons opt for interrupted stitches reinforced with pledgets to close these defects, a running suture can also be used and, in our opinion, is a reliable and rapid alternative technique.

The Threat of Adhesive Embolization: BioGlue Leaks Through Needle Holes in Aortic Tissue and Prosthetic Grafts

BACKGROUND

BioGlue Surgical Adhesive (CryoLife, Inc, Kennesaw, GA) is used to reinforce anastomoses during cardiovascular operations. Previous reports have raised concerns that adhesives may leak through suture-line needle holes and that resulting intraluminal glue may embolize. The purpose of this study was to determine if BioGlue leaks through anastomotic needle holes in aortic tissue and two common prosthetic graft materials.

METHODS

Polypropylene suture was used to create end-to-end anastomoses in gelatin-sealed woven polyester grafts (n = 45), expanded polytetrafluoroethylene (ePTFE) grafts (n = 45), and fresh porcine aortas (n = 45). An additional 45 anastomoses were created in ePTFE grafts using ePTFE sutures. The outer surface of each anastomosis was covered with BioGlue. Anastomoses underwent inspection with direct magnification or histology.

RESULTS

BioGlue leaked through needle holes and into the lumen in 10% of anastomoses (18 of 180). Leaks were significantly more common in fresh aorta (10 of 45, 22%) than in prosthetic grafts (8 of 135, 6%; p = 0.003). Suture size did not significantly affect the incidence of leak. The use of ePTFE sutures did not eliminate BioGlue leakage. Prosthetic graft leaks created discreet round adhesive particles. In contrast, aortic tissue leaks resulted in thin, friable flakes of glue extending along the intimal surface. Aortic histology confirmed that BioGlue reached the vessel lumen via the suture channels.

CONCLUSIONS

BioGlue leaked through the needle holes in fresh aortic tissue and prosthetic grafts. Intraluminal adhesive particles were easily dislodged, supporting concerns regarding embolization. The potential for adhesive embolization should be a factor when considering the relative risks and benefits of using BioGlue.

Prospective randomized study of a protein-based tissue adhesive used as a hemostatic and structural adjunct in cardiac and vascular anastomotic repair procedures

BACKGROUND

The purpose of this study was to determine whether adjunctive use of the bovine serum albumin and glutaraldehyde tissue adhesive BioGlue (BioGlue Surgical Adhesive; CryoLife, Inc) could reduce the rate of anastomotic bleeding in patients undergoing cardiac and vascular repair procedures when compared with a standard repair control. This was a prospective multicenter, randomized, controlled clinical trial conducted in accordance with the IRB at each participating institution.

STUDY DESIGN

A total of 151 patients consented to participation and were randomly assigned to standard repair plus BioGlue (n = 76) or standard repair alone (n = 75). These two groups were statistically homogeneous for age, gender, race, procedure, and number of anastomoses. Patients underwent cardiac procedures (n = 49), aortic procedures (n = 105), or peripheral vascular procedures (n = 48).

RESULTS

Anastomotic bleeding was significantly reduced in the BioGlue group (18.8% of anastomoses) compared with the control group (42.9% of anastomoses, p < 0.001). Pledget use was reduced in the BioGlue group (26.2%) compared with the control group (35.9%, p = 0.047). Days in the ICU and total days in the hospital were slightly higher in the control group. Adverse event profiles were equivalent between the two groups except for occurrence of neurological defects, which were threefold less in the BioGlue group (p = 0.009).

CONCLUSIONS

This study demonstrates that using BioGlue as an adjunct to standard repair methods is safe and significantly reduces the occurrence of intraoperative anastomotic site bleeding in cardiac and vascular repair patients. Using BioGlue along suture lines reinforces anastomoses, thus minimizing pledget use.

Fibrin sealants in surgical practice: An overview

The need to effectively manage hemostasis and tissue sealing during surgery has had a strong influence on the development of modern surgical techniques. A group of agents known as surgical tissue adhesives has been developed to promote hemostasis and tissue sealing during surgery, and these comprise both natural and synthetic agents. Fibrin sealants are the most effective tissue adhesives currently available, and they are biocompatible and biodegradable. The fibrin sealants are comprised of purified, virus-inactivated human fibrinogen, human thrombin, and sometimes added components, such as virus-inactivated human factor XIII and bovine aprotinin. These agents mimic the final steps of the physiological coagulation cascade to form a fibrin clot. The use of any plasma-derived product in the surgical setting carries a potential risk of viral transmission. In fact, it was the risk of viral transmission from fibrinogen and thrombin that halted development work on fibrin sealants in the United States. Since that time, new techniques for isolating and concentrating plasma fractions have been developed, and national and international guidelines have been introduced to ensure the safety of all plasma products. All plasma donors are carefully selected and their plasma units screened for viral contamination before processing. All plasma donations and bovine tissue used in the production of commercial fibrin sealants undergo rigorous viral reduction/elimination steps. As a result of this carefully controlled and monitored process, there have been no proven cases of viral transmission associated with the use of commercial fibrin sealant. Fibrin sealants are currently used in a number of surgical specialties, including cardiovascular surgery, thoracic surgery, neurosurgery, plastic and reconstructive surgery, and dental surgery. The use of fibrin sealants has a positive effect on surgical outcomes, such as improved time to hemostasis, reduced blood loss, and reduced complications. This review describes the development of fibrin sealants, the composition of currently available products, and their use in surgical practice.

Commercial fibrin sealants in surgical care

Fibrin sealants can be a valuable adjunct to surgical procedures. A variety of commercial products have been developed. Specific uses include hemostasis, tissue sealing, and even drug delivery. This review summarizes the components, mechanism of action, and clinical uses of fibrin sealants in modern surgical care.

Management of ventricular septal defect: a survey of practice in the United Kingdom

BACKGROUND

A survey of pediatric cardiac surgeons was performed to establish current opinions in the United Kingdom concerning closure of ventricular septal defect.

METHODS

Questionnaires were sent to 14 pediatric cardiac centers in 1995 (16 surgeons, 100% response), and again in 1997 (20 surgeons, 100% response).

RESULTS

Results are presented for 1997, with findings from 1995 shown in parentheses. Eleven (6) surgeons used bypass exclusively, 9 (10) sometimes used circulatory arrest. Operative techniques were similar, although the material used for the patch varied. Multiple defects were approached via the transatrial route by 18 (15), right ventriculotomy by 11 (7) and left ventriculotomy by 7 (6). The juxta-arterial defect was approached via the transpulmonary route by 16 (13), a combination by 9 (11), transatrial by 10 (6), and transventricular by 9 (5). The most common indications for pulmonary arterial banding were "Swiss cheese" defect for 13 (13), and functionally single ventricle for 5 (6). Ventricular septal defect associated with coarctation was repaired in two stages by 13 (10), a single stage by 5 (3), or either by 1 (3).

CONCLUSIONS

Pediatric cardiac surgeons in the United Kingdom demonstrate a uniform, evidence-based approach to the management of ventricular septal defect.