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Ann Thorac Surg 1995;59:761-763
© 1995 The Society of Thoracic Surgeons

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Case Reports

Aortic Dissection Repair With GRF Glue Complicated by Heart Block

Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa

Accepted for publication September 9, 1994.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Gelatin-resorcin-formaldehyde-glutaraldehyde (GRF) biologic glue is an available adjunct to repair acute ascending aortic dissections. Permanent complete heart block complicated the operative repair of 2 of 6 patients. The pathophysiology of heart block resulting from either the acute dissecting process or the technique of applying GRF glue is discussed.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Refixation of dissected aortic layers with gelatin-resorcin-formaldehyde-gluteraldehyde (GRF) tissue adhesive (Colle Biologique Gélatine Résorcine Formol; Cardial, Saint-Etienne, France), either as an adjunct to prosthetic graft replacement of the aorta [1] or as the definitive procedure [2,3], is an available option in the operative treatment of aortic dissections. The gelatin-resorcin mixture (15 mL; 15 volumes gelatin, 5 volumes resorcinol, 20 volumes water) is injected into the space between the two dissected layers, and a polymerizing agent (5 mL; 9 volumes 18.5% formaldehyde, 1 volume 25% glutaraldehyde) is then added with a blunt injector, and the compound mixed for 30 to 45 seconds to obtain a whitish dense adhesive agent. GRF glue toughens and reinforces tissue, in addition to binding the two friable acutely dissected aortic wall layers together, thus allowing for an easier and safer repair.

Cardiac centers that use GRF glue for Stanford type A acute aortic dissections all have reported improved results and no complications from its use [2–4]. We used GRF glue to reapproximate the proximal dissected aortic sinuses in 6 patients, and complete atrioventricular block occurred in 2 of these patients.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
Acute ascending aortic dissection, moderate aortic insufficiency, as well as an aorta to right atrial fistula was diagnosed on echocardiography in a 60-year-old woman with precordial chest pain. The preoperative electrocardiogram showed 114 beats/min normal sinus rhythm with an incomplete right bundle-branch block pattern (PR interval, 148 ms; QRS duration, 84 ms; R axis, +104 degrees). Aortography was not done.

Cardiopulmonary bypass was instituted through a femoral artery and direct bicaval cannulation. An acute dissection involving only the ascending aorta, but with aneurysmal dilation of the false channel that had ruptured into the right atrium, was found. The communication in the roof of the right atrium was closed by direct suture, the aortic valve resuspended with pledget-supported sutures, and the two dissected layers that extended to the full depth of both the right and noncoronary sinuses were reapproximated with GRF glue. A 26-mm zero porosity collagen impregnated woven Dacron graft (Hemashield; Meadox Medical Inc, Oakland, NJ) then was interposed above the coronary ostia to the aortic arch, with resection of the intervening ascending aorta and concavity of the arch. The repair was done using a period of hypothermic (18°C) circulatory arrest with retrograde cerebral perfusion (31 minutes) during 3 hours 17 minutes of cardiopulmonary bypass. Myocardial protection was with antegrade multidose St. Thomas' Hospital No. 2 cardioplegic solution (St. Thomas Cardioplegia; Adcock Ingram Critical Care Ltd, Johannesburg, South Africa) and intermittent topical hypothermia during a 2-hour 19 minute aortic cross-clamp period.

A VVIR pacemaker was inserted because of postoperative complete atrioventricular heart block with a 47-beat/min right bundle-branch block pattern ventricular escape rhythm (QRS duration, 128 ms; R axis, +154 degrees) before hospital discharge on the 16th postoperative day.

Patient 2
An acute ascending aortic dissection with moderate aortic insufficiency was diagnosed on echocardiography in a 52-year-old hypertensive patient with acute precordial chest pain. The preoperative electrocardiogram showed a 87-beat/min normal sinus rhythm with no conduction abnormalities (PR interval, 176 ms; QRS duration, 108 ms; R axis, +67 degrees).

Cardiopulmonary bypass was instituted through a femoral artery and bicaval cannulation through the right atrium. The aortic valve was resuspended with pledget-supported sutures, the two dissected layers, which extended to the full depth of both the right and noncoronary sinuses, were reapproximated with GRF glue, and a 30-mm Dacron graft (Hemashield) was interposed above the coronary ostia to the aortic arch. Hypothermic (18°C) circulatory arrest with retrograde cerebral perfusion (28 minutes) was used during 2 hours 25 minutes of cardiopulmonary bypass. Myocardial protection was combined antegrade and retrograde multidose St. Thomas' Hospital No. 2 cardioplegic solution as well as intermittent topical hypothermia during a 1 hour 23 minute aortic cross-clamp period.

Hospital discharge was on the 12th postoperative day after insertion of a VVI pacemaker because of postoperative complete atrioventricular heart block with a 66-beat/min right bundle-branch block pattern ventricular escape rhythm (QRS duration, 140 ms; R axis +86 degrees).

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

 
We report two patients with acute type A dissections in whom permanent complete atrioventricular heart block occurred after GRF glue was used to repair the proximal aortic stump.

Heart block secondary to dissecting aneurysms of the aorta from hematomas of the interatrial septum has been described previously [5]. The aortic media is continuous with the annulus of the aortic valve except in the region of the commissures. Thus, a dissecting hematoma involving the commissure between the noncoronary and right coronary sinuses may enter the aortoatrial space, advance into the interatrial septum, and impinge on the penetrating bundle of His (Fig 1). In both of our patients the right noncoronary commissure was dissected and hence the dissection had entered the aortoatrial space, which probably accounted for any preoperative minor atrioventricular conduction abnormalities. However, preoperative atrioventricular conduction abnormalities do not necessarily progress to complete heart block after operative repair [6]. Furthermore, no sutures or incisions were placed in the vicinity of the conduction tissue in either patient. Our first patient also had an associated aortocameral fistula, which is a rare complication of aortic dissection, but the fistula was in the roof of the right atrium, well away from the interatrial septum and conduction tissue.

View larger version (67K): [in this window] [in a new window]   Fig 1. . Schematic diagram of the left ventricular outflow tract showing a cross-section of the ``dissected'' aortic wall in the region of the right fibrous trigone. (Based in principle on the work of Yacoub and colleagues [5].)

However, the technique of using GRF glue may have played a role in causing heart block. Bachet and Guilmet and their colleagues [1, 3] limit the glued area by initially approximating the dissected layers with a continuous polypropylene suture placed just above the aortic annulus, thereby possibly preventing any direct penetration of GRF glue into the aortoatrial space. Nevertheless, approximating sutures were not used by other surgeons who have also not reported heart block [4]. The dissection process, however, does not involve the aortoatrial space in all patients. This was noted at operation in at least one of our patients in whom postoperative heart block did not occur (this retrospective information was not available in our other patients). In addition, the volume of polymerizing agent used, and depth of injection into the mixture may also be important; only two to three drops polymerizer per 1 mL of gelatin-resorcin mixture is necessary [1]. In both of our patients approximately 2 to 3 mL of polymerizer was injected into the depth and throughout the gelatin-resorcin mixture instilled into the dissected space.

In conclusion, we infer that the aldehyde components of GRF glue may cause permanent complete heart block when used to reapproximate acutely dissected aortic sinuses. This risk may be minimized if either the dissection process does not involve the right noncoronary commissure and therefore the aortoatrial space, or if care is taken to only apply minimal quantities of the polymerizer and not into the full depth of the dissected space.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment References

 
Address reprint requests to Dr von Oppell, Department of Cardiothoracic Surgery, School of Medicine, University of Cape Town, 7925 Cape Town, South Africa.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Bachet J, Goudot B, Teodori G, et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue: a twelve-year experience. J Cardiovasc Surg (Torino) 1990;31:263–73.[Medline]
2. Fabiani JN, Jebara VA, Deloche A, Stephan Y, Carpentier A. Use of surgical glue without replacement in the treatment of type A aortic dissection. Circulation 1989;80(Suppl 1):264–8.
3. Guilmet D, Bachet J, Goudot B, Dreyfus G, Martinelli GL. Aortic dissection: anatomic types and surgical approaches. J Cardiovasc Surg (Torino) 1993;34:23–32.[Medline]
4. Weinschelbaum EE, Schamun C, Caramutti V, Tacchi H, Cors J, Favaloro RG. Surgical treatment of acute type A dissecting aneurysm, with preservation of the native aortic valve and use of biologic glue: follow-up to 6 years. J Thorac Cardiovasc Surg 1992;103:369–74.[Abstract]
5. Yacoub MH, Schottenfeld M, Kittle CF. Hematoma of the interatrial septum with heart block secondary to dissecting aneurysm of the aorta: a clinicopathologic entity. Circulation 1972;46:537–45.[Abstract/Free Full Text]
6. Page AJF, Yacoub MH, Sutton GC. Aorto-right atrial fistula: a rare complication of aortic dissection. Br Heart J 1973;35: 1338–40.[Free Full Text]
7. Steiner C, Kovalik ATW. A simple technique for production of chronic complete heart block in dogs. J Appl Physiol 1968;25:631–2.[Free Full Text]
8. Karpawich PP, Bharati S, Roskamp JO, Lev M. Selective transepicardial ablation in the immature canine myocardium: a more precise method. J Thorac Cardiovasc Surg 1989;97:893–9.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David Chimuka Johan G. Brink Peter Zilla Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Von Oppell, U. O. Articles by Zilla, P. Search for Related Content PubMed PubMed Citation Articles by Von Oppell, U. O. Articles by Zilla, P.