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Ann Thorac Surg 1995;60:515-516
© 1995 The Society of Thoracic Surgeons
DR PEDRO J. del NIDO (Pittsburgh, PA): Did you see any evidence or incidence of neurologic problems? Obviously, one of the concerns would be if you accidentally dropped some of the glue into the left side of the heart.
DR VON SEGESSER: We did not see any of these problems. However, it is true that one has to use a proper technique. And as I said, it is useful to rub the surface to get better adhesion and, of course, no glue should drop on blood because it would not stay there and could be embolized. Until now we have not had that problem.
DR CHARLES B. HUDDLESTON (St. Louis, MO): At what stage after the operation was the echocardiogram performed? Also, I presume by the hemodynamic significance those 2 patients had to return to the operating room for closure.
DR VON SEGESSER: Yes.
DR HUDDLESTON: I would agree with concerns with embolization as Dr del Nido pointed out. It seemed like that would produce a thrombogenic surface over and above what the patch produces itself on the left side of the heart.
DR VON SEGESSER: With regard to the thrombogenic surface I think one can say that in adult cardiac operations we often have clots in the aorta and aneurysms that stay there for years without embolization. I think it is not necessarily a problem to have a clot there.
I also believe that if the patch reaches the surface with a small angle, this region would clot off anyway, and if you have no flow in a place, you will have a clot there also. And there are some technical aspects to improve the resistance of the glue. I think it is helpful to produce a plug that has larger ends on both sides. And here in this application the glue is taken into the suture, therefore I think the risk of embolization is very low.
DR RUEDIGER LANGE (Heidelberg, Germany): As far as I know fibrin glue is resorbed within approximately 3 days. Do you use a different glue or do you have any information on this issue? My second question is, at what time after the operation did you perform the echocardiographic examinations? If it was beyond 3 days after operation, there should not be any difference because by that time there is no fibrin glue left. Could you comment on whether your observed difference in residual shunting was maybe due to the difference in suture technique, interrupted versus continuous, than due to the application of fibrin glue?
DR VON SEGESSER: With regard to the resorption of the glue, I can say that there has been a study done by Leca and colleagues from Paris where they have glued multiple ventricular septal defects (VSDs) experimentally first and clinically thereafter, and they found in the experimental setup that the glue was replaced by scar tissue and they had no recurrence and no reoperations in their group.
With regard to the echocardiogram, we did several echocardiograms: one early after operation, one before discharge, and one between 3 and 6 months.
DR CARL L. BACKER (Chicago, IL): I am curious as to your thoughts about the interrupted suture technique for closure of VSDs. We have published our results with interrupted pledgeted sutures and an elastic Dacron patch, a technique that was developed by Farouk Idriss. With both small VSDs and with conal VSDs, we have had essentially no residual VSDs using that technique. I think the ideal operation for a VSD, at least at our institution, is closure with interrupted pledgeted sutures and a Dacron patch, and I wonder if you could comment on why you did not try that technique.
DR VON SEGESSER: Well, I think we have to state clearly that here we are not talking about residual VSDs that have to be reoperated on. These are things that you find in the reports of the cardiologists that normally are called trivial VSDs, and you find these in all series that are published. You would not even see these VSDs at angiography or if you do oxygen saturations; you would not detect any of these. So with regard to the interrupted suture technique, I believe that this would not help in this application, because you still can have incongruences between the patch on one side and the myocardium on the other, which cannot be occluded with sutures everywhere. And if I understood correctly, you used a Dacron patch. It would probably not even be tight in the beginning but only later on, and what makes it tight finally is a clot all over the surface.
DR MICHAEL A. GREENE (Gainesville, FL): I was wondering if the source of the fibrinogen exposes the patient to any infectious risk.
DR VON SEGESSER: I think that is a very important question. The glue used at this time has not been reported to be linked to transmission of infectious diseases. There have been a number of precautions taken. It is thermally inactivated material on one side. And although there has never been a transmission reported, there are PCR techniques used to avoid batches that could be contaminated. Therefore, I believe the risk of transmission of infectious disease is extremely low.
DR CONSTANTINE E. ANAGNOSTOPOULOS (New York, NY): I have been fortunate to use the fibrin glue in New York and the resorcinol glue when I go to Athens. If you really want complete elimination of criticism from cardiology, are you willing to spend 10 minutes so you can use the resorcinol glue? Have you thought of that? Or do you want a little criticism?
DR VON SEGESSER: We use the resorcin glue, or French glue, for aortic dissections. I am not sure if here it would be a good application because of the conduction tissue. As you know, resorcin glue contains formalin, and I believe that fixation of the conductive tissue might not be ideal.
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