Effective Use of Fibrin Glue for Acute Aortic Dissection

Neomedia Repair of the Valsalva Sinus in the Treatment of Acute Type-A Aortic Dissection: Long-term Effectiveness and a Case of Pathology

Although numerous surgical techniques are employed to treat acute Stanford type A aortic dissection (ATAAD), controversy remains over which is the best procedure for aortic root reconstruction. Among the various techniques utilized, neomedia repair is considered to be more promising than adhesive-only repair for the treatment of a dissected aortic root. We experienced a series of neomedia sinus Valsalva repair using woven polyester fabric, and evaluated the aortic root diameter by computed tomography and severity of aortic valve insufficiency by transthoracic echocardiography. The aortic root diameter was well preserved with no progress of aortic valve insufficiency in the long-term period. Furthermore, we found that the fabric looked functioning new media in the findings obtained from the pathological examination of a neomedia repaired aortic wall sample that was obtained by chance from a patient during valve replacement surgery performed 10 years after aortic reconstruction for ATAAD. Neomedia repair using woven polyester fabric for ATAAD might facilitate the long-term durability of the surgically treated aortic root. (This is a translation of J Jpn Coll Angiol 2019; 59: 37–43.)

Reinforcement and reapproximation of the aortic stump during surgery for acute aortic dissection

Anastomosis of the fragile aortic wall in patients with acute aortic dissection presents a challenge to cardiovascular surgeons. Reinforcement of the stump is a key to accomplishing successful anastomosis. Surgical glues such as gelatin-resorcin-formalin (GRF) glue and Bioglue are easy to use and have radically changed the process of the reinforcement and reapproximation. However, as surgical glues have been associated with disadvantages such as tissue necrosis, enthusiasm for their use has waned. In this review, we discuss the various methods for reinforcement and reapproximation of the aortic stump during operations for acute aortic dissection, mainly outside the category of surgical glues.

[A revised modified bentall's procedure using aorto-prosthetic hemostatic suture]

nema

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.

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.