Off-pump epicardial tissue sealing—a novel method for atrioventricular disruption complicating mitral valve procedures

Survival of left ventricular rupture post mitral valve replacement

A fatal and uncommon complication after mitral valve replacement is left ventricular (LV) rupture. We describe a case of a woman in her 40s with rheumatic heart disease and mitral regurgitation who underwent mitral valve replacement on cardiopulmonary bypass and experienced LV rupture but survived this catastrophe.

Midterm outcomes of mitral valve repair versus replacement in elderly patients: A propensity score-matched analysis

BACKGROUND

Current literature reports better short-term mortality rates in mitral valve repair over replacement in elderly patients. However, valve durability, postoperative complications, and reintervention rates in these cohorts remain understudied. As such, we aimed to investigate 5-year rates of mortality and reoperation after initial mitral repair or replacement in elderly patients.

METHODS

Using the TriNetX Research Network database, we identified patients aged ≥70 who underwent mitral valve repair or replacement for nonrheumatic mitral insufficiency between January 2010 and December 2020. We 1:1 propensity score-matched cohorts for 33 covariates including demographics, comorbidities, and surgical history. After matching, we compared 5-year mortality and reoperation rates between cohorts using Kaplan-Meier estimates and multivariable Cox proportional hazards models.

RESULTS

We compared 823 mitral valve repair patients to a propensity score-matched cohort of 823 mitral valve replacement patients over a 5-year follow-up period. All variables of interest were adequately matched. Cumulative 5-year mortality rate was significantly lower among mitral valve repair patients (17.0% vs. 24.9%; hazard ratio [HR]: 0.66, 95% confidence interval [95% CI]: 0.51-0.87, p < 0.0025). Reoperation rates at 5-year did not differ (2.6% vs. 2,1%; HR: 1.34, 95% CI: 0.67-2.68, p = 0.401).

CONCLUSIONS

We observed lower 5-year mortality rates and nonsignificantly different reoperation rates among elderly patients with mitral regurgitation undergoing mitral valve repair compared to replacement. Our data support the current understanding that mitral valve repair should be considered as the first treatment line whenever possible, even in elderly patients.

Sufficient cardiac unloading by Impella 5.0 in left ventricular rupture following mitral valve replacement: a case report

A 72-year-old woman presented with exertional dyspnea. Echocardiography revealed severe mitral valve stenosis; therefore, mitral valve replacement was performed using a bioprosthetic valve. However, left ventricular wall rupture occurred following mitral valve replacement. Under re-cardiac arrest, we found a left ventricular tear under the posterior annulus of the mitral valve. We repaired the left ventricular muscle using a bovine pericardial patch and implanted a bioprosthetic valve again. Postoperatively, we implanted an Impella 5.0 heart pump through the right axillary artery to ensure left ventricular wall unloading. Systemic blood flow depended almost completely on mechanical circulatory assistance until postoperative day 3. After the fourth postoperative day, we started weaning the patient from Impella 5.0. Finally, it was completely discontinued on the sixth postoperative day. After that, the patient's condition was stable, and she was discharged 44 days postoperatively. Impella 5.0 is a potentially beneficial device for left ventricular unloading in patients with left ventricular wall rupture following mitral valve replacement.

Mortality Rates of Surgical Techniques for Correcting Atrioventricular Disjunction

We compared the mortality rates of two surgical techniques for correction of atrioventricular disjunction in 10 out of 720 patients who underwent mitral valve replacement from 2005 to 2012. In group I, the mitral annulus was fixed with bovine pericardial strips; in group II, a 'patch' of bovine pericardium was sutured and extended from the base of the lateral and medial papillary muscles, covered the posterior wall of the left ventricle, went through the posterior mitral annulus, and ended in the posterior wall of the left atrium adjacent to the mitral ring. The group II technique showed a lower mortality.

[Use of topical haemostatic agents in cardiovascular surgery]

The problem of haemostasis in cardiovascular surgery is of current concern. Recent trends are towards increased use of topical haemostatic agents. Tachocomb has been used for more than 30 years in abdominal surgery and oncology. The purpose of the present publication is to analyse the literature data and formulate the indications for the use of Tachocomb in cardiovascular surgery. Multicenter randomized and local studies have demonstrated efficacy of Tachocomb in treatment of surgical haemorrhage in operations on the heart, thoracic aorta, carotid arteries and lower-limb arteries, resulting in significantly decreased time to achieve haemostasis, decreased volume of blood loss and haemotrasfusion, as well as reduced frequency of complications. Also shown was economic efficacy, including a shortened length of patients' hospital stay. This is followed by describing a wide spectrum of examples of alternative use of Tachocomb, including its use for seamless closure of defects of cardiac chamber walls, aero- and lymphostasis, prevention of formation of commissures. Convincing experimental and clinical results make it possible to formulate a series of indications for the use of Tachocomb in cardiovascular surgery.

Off-pump sutureless repair for ischemic left ventricular free wall rupture: a systematic review

Background

Clinical results of ischemic left ventricular free-wall rupture show high mortality rates.

Methods

We reviewed studies published after 1993 on PubMed.

Results

A sutureless technique using fibrin glue sheets or patches with/without fibrin glue might contribute to improved clinical results. However, some technique limitations remain for blowout-type ruptures, and the possibility of a pseudoaneurysm formation at the repair site after surgery should be considered.

Conclusions

The sutureless technique can be a promising strategy for the treatment of ischemic rupture, but serial echocardiographic studies should be mandatory for diagnosing a left ventricular pseudoaneurysm formation thereafter.

The Use of a Surgical Patch Coated With Human Coagulation Factors in Surgical Routine: A Multicenter Postauthorization Surveillance

Local hemostyptic agents are of great value to significantly reduce bleeding complications and various devices have become available for clinical use. The aim of this multicenter postauthorization surveillance was to study the surgeons’ expectations regarding efficacy and safety of the surgical patch coated with human coagulation factors (TachoSil) under routine clinical conditions. A total of 408 patients had been included in this trial and the patients had to have an expected increased bleeding risk either due to patient related hemorrhagic risk factors or operations associated with an expected increase of bleeding complications. The main types of surgical interventions were operations on the liver (26%), vascular system (16%), gastrointestinal tract (10%), heart (8%), kidney (7%), thorax (7%), spleen (4%), and pancreas (4%). Other operations (18%) were reported in the fields of neurosurgery, urology, gynecology, dermatology, and on the thyroid gland. Based on subjective assessments the results have shown that TachoSil has met the surgeons’ expectations to be efficacious and safe as a hemostatic treatment in a broad variety of surgical interventions. The observed benefits far exceed the frequencies of complications and many of the observed benefits easily translate into cost savings. In almost 50% of the cases the surgeons thought that the use of the topical hemostat TachoSil may have led to savings in blood component therapy. The savings of intra- and postoperative transfusions may lead to less frequent transfusion-related adverse effects and the lower probability of postoperative complications is of clinical importance. In particular, it is worth mentioning that based on the surgeons’ assessment, the use of TachoSil may have helped to save the organ in 17% of the cases. Thus, these clinically relevant benefits may offer opportunities for improvements of hemostasis in patients at risk for bleeding complications and may facilitate the management of excessive bleeding.

Efficacy and safety of human fibrinogen-thrombin patch (Tachosil(®)) in the management of diffuse bleeding after chest wall and spinal surgical resection for aggressive thoracic neoplasms

Diffuse bleeding after chest wall and spine resection represents a major problem in General Thoracic Surgery. Several fibrin sealants (FS) have been developed over the years and their use has been gradually increasing over time, becoming an important aid to the surgeons, justifying their use across numerous fields of surgery due to its valid haemostatic properties. Among the several FS available, TachoSil(®) (Takeda Austria GmbH, Linz, Austria) stands out for its haemostatic and aerostatic properties, the latter being demonstrated even in high-risk patients after pulmonary resections for primary lung cancers. Several papers available in literature demonstrated TachoSil(®)'s effectiveness in controlling intraoperative and postoperative bleeding in different surgical branches, including hepatic and pancreatic surgery, as well as cardiac and thoracic surgery. However, the use of TachoSil(®) to control diffuse bleeding following major resections for advanced lung cancers, with requirement of chest wall and vertebral body resection for oncological radicality, was never published so far. In this paper, we report three cases of pulmonary lobectomy associated to chest wall resection and haemivertebrectomy for primary malignant lung neoplasms and for a recurrence of malignant solitary fibrous tumour of the pleura in which we used TachoSil(©), which demonstrated its efficacy in controlling diffuse bleeding following resection.

Late Chronic Tamponade after Intraoperative Right Ventricular Rupture Repair with Mediastinal Fat

Advanced age and female sex are known risk factors for ventricular wall rupture during open-heart procedures. We present the case of an 83-year-old female patient with an intraoperative traumatic right ventricular free wall rupture during an aortic valve replacement procedure. Pledgetted interrupted sutures reinforced with large pieces of mediastinal fat were used for rupture repair. After 6 months, the patient was readmitted with the diagnosis of a retrosternal mediastinal mass and clinical signs of cardiac tamponade that required reoperation.

Adhesive and sealant interfaces for general surgery applications

The main functions of biological adhesives and sealants are to repair injured tissues, reinforce surgical wounds, or even replace common suturing techniques. In general surgery, adhesives must match several requirements taking into account clinical needs, biological effects, and material features; these requirements can be fulfilled by specific polymers. Natural or synthetic polymeric materials can be employed to generate three-dimensional networks that physically or chemically bind to the target tissues and act as hemostats, sealants, or adhesives. Among them, fibrin, gelatin, dextran, chitosan, cyanoacrylates, polyethylene glycol, and polyurethanes are the most important components of these interfaces; various aspects regarding their adhesion mechanisms, mechanical performance, and resistance to body fluids should be taken into account to choose the most suitable formulation for the target application. This review aims to describe the main adhesives and sealant materials for general surgery applications developed in the past decades and to highlight the most important aspects for the development of future formulations.

Left ventricular rupture postmitral valve replacement: surviving a catastrophe

One of the dreaded mechanical complications of mitral valve replacement (MVR) is rupture of the left ventricle (LV). This report describes the early diagnosis and successful repair of rupture of posterior wall of LV in an elderly patient who underwent MVR. We have discussed the risk factors and perioperative issues implicated in such complication. The anesthesiologist as an intra-operative echocardiographer can aid in identifying the patient at risk. Though important surgical steps are necessary to prevent the complication; nonetheless, the anesthesiologist needs to take key measures in the perioperative period.

Repair of left atrioventricular disruption after mitral valve replacement using extracorporeal life support system for effective ventricular unloading

Atrioventricular (AV) disruption is a rare but fatal complication after prosthetic mitral valve replacement. Surgical management is controversial and ranges from epicardial tissue sealing to open repair using autologous or xenogenic patch techniques to autotransplantation of the heart. We report the successful repair of an AV disruption Type I using an extracorporeal life support (ECLS) system for effective ventricular unloading followed by epicardial patch closure. The surgical management of AV disruption benefits from the use of ECLS, as it allows effective decompression of the heart without requiring full heparinization.

Polyglycolic acid sheet with fibrin glue potentiates the effect of a fibrin-based haemostat in cardiac surgery

BACKGROUND

Hemorrhage from the left ventricle can be critical and sutureless repair using a fibrin-based haemostat (TachoComb) is one effective option. When active hemorrhage is not controlled by the haemostat, we have used a polyglycolic acid (PGA) sheet and fibrin glue in addition. Here we investigated whether the PGA sheet and fibrin glue combined with TachoComb had stronger adhesive properties than TachoComb alone in two experimental models.

METHODS

Experiment 1. An airtight circuit that included rabbit skin with holes covered by each type of sealant was gradually pressurized and the burst pressure was recorded automatically (n = 10). Experiment 2. A suture loop was attached to a porcine heart by each sealant, and the peel-off pressure was measured (n = 12).

RESULTS

The PGA sheet and fibrin glue combined with TachoComb showed significantly higher adhesive strength than TachoComb alone in both experiments (p < 0.05).

CONCLUSIONS

Adding a PGA sheet and fibrin glue increased the adhesive strength of TachoComb in two experimental models, suggesting that this method might be effective for achieving haemostasis in difficult clinical situations.

Polyglycolic acid sheet with fibrin glue potentiates the effect of a fibrin-based haemostat in cardiac surgery

Background

Hemorrhage from the left ventricle can be critical and sutureless repair using a fibrin-based haemostat (TachoComb) is one effective option. When active hemorrhage is not controlled by the haemostat, we have used a polyglycolic acid (PGA) sheet and fibrin glue in addition. Here we investigated whether the PGA sheet and fibrin glue combined with TachoComb had stronger adhesive properties than TachoComb alone in two experimental models.

Methods

Experiment 1. An airtight circuit that included rabbit skin with holes covered by each type of sealant was gradually pressurized and the burst pressure was recorded automatically (n = 10). Experiment 2. A suture loop was attached to a porcine heart by each sealant, and the peel-off pressure was measured (n = 12).

Results

The PGA sheet and fibrin glue combined with TachoComb showed significantly higher adhesive strength than TachoComb alone in both experiments (p < 0.05).

Conclusions

Adding a PGA sheet and fibrin glue increased the adhesive strength of TachoComb in two experimental models, suggesting that this method might be effective for achieving haemostasis in difficult clinical situations.

The rupture of atrioventricular groove after mitral valve replacement in an elderly patient

Rupture of the left ventricle after mitral valve replacement, although infrequent, may be a highly lethal complication. This report describes the early diagnosis and successful repair of rupture of atrioventricular groove in an elderly patient who underwent mitral valve replacement.

Fibrin sealant patch for repair of acute type a aortic dissection

INTRODUCTION

The use of glues to repair disrupted tissue during acute type-A aortic dissection (TAD) surgery may be discontinuous, and cause embolization and cell necrosis. We report a method of fibrin sealant patch (FSP) to reinforce dissected aortic tissue with a collagen double layer coated with fibrinogen/thrombin on either side (TachoSil®; Takeda, Konstanz, Germany).

METHODS

In 12 patients (seven male, 66.9 ± 11.7 years) with acute TAD we performed FSP of the intima-media disruption at the proximal and distal anastomosis of the aorta. We analyzed the perioperative course and echocardiographical, radiological, and clinical outcomes up to one year. Additionally, we investigated the adhesive potential of the FSP in vitro.

RESULTS

In vitro, the adhesive strength of the FSP was 60 N/cm(2). In-hospital mortality was 8.3% (n = 1), recovery was satisfactory with no major neurologic events, mean ICU stay was 13.6 ± 6.0 days, mean hospital stay was 20.7 ± 4.4 days. A total of 7.0 ± 2.6 RBC, 3.4 ± 1.5 platelets, and 8.0 ± 4.3 FFP were transfused. One-year survival was 83.3%. In 6/6 DeBakey II dissections the intimal tear was completely resected, in 2/6 DeBakey I dissections the false lumen in the descending aorta completely collapsed. No redissections and no relevant aortic valve insufficiencies were seen during follow-up.

CONCLUSION

This analysis shows that FSP using a collagen matrix double layer coated with fibrinogen/thrombin is feasible, safe, and effective in repairing the dissected aortic tissue. It results in continuous reinforcement of aortic tissue and completely avoids the need for conventional glues.

Repair of coronary artery perforation following angioplasty using TachoSil patches

Coronary perforation is a rare complication of percutaneous interventional procedures, occurring in 0.2-3% of procedures, which may require emergency coronary bypass surgery. We describe here an alternative method to deal with such complication, which proved effective in a patient with active bleeding from the left anterior descending (LAD) coronary artery. By temporary pressing on beating heart patches of TachoSil, a sponge impregnated with human fibrinogen and thrombin, on the bleeding site, complete and stable hemostasis was achieved.

Left ventricular rupture post mitral valve replacement

Prevention is better than cure best applies here. As per many authors, posterior leaflet chordae preservation prevent Left ventricular rupture (LVR) and preserve LV geometry. We are presenting here 5 types of left ventricular rupture (LVR) post Mitral valve replacement (MVR) with different methods to repair with the advantages and disadvantages of each. The mortality rate is still very high despite the advances in cardiac surgery. Many therapeutic approaches have been adopted. Yet, none is ideal.

Left ventricular pseudoaneurysm following mitral valve repair

We present a rare case of a left ventricular pseudoaneurysm following mitral valve repair probably due to testing the valve's competence. The pseudoaneurysm was treated successfully with a sutureless technique in which layers of a biodegradable collagen system with fibrinogen-based coating were used. We reviewed the literature regarding left ventricular rupture following mitral valve surgery published from 1990 until 2006. Overall, the incidence of this complication was 0.56% for 10978 operations, and the mortality rate was 57.4%. We also describe a possible mechanism common to all forms of left ventricular rupture.

Fibrin Sealant for Left Ventricular Rupture after Mitral Valve Replacement

Despite safer surgical procedures, left ventricular rupture remains a rare but potentially lethal complication of mitral valve replacement. The use of fibrin sealant has substantially improved the outcome of many difficult bleeding episodes after cardiac surgery. We describe a case of left ventricular rupture successfully treated with fibrin sealant combined with external Teflon-pledgeted sutures.