Ann Thorac Surg 2001;72:1733-1735
© 2001 The Society of Thoracic Surgeons
Case report
Ostial stenosis of coronary arteries after complete replacement of aortic root using gelatin-resorcinol-formaldehyde glue
Hiroyuki Tsukui, MD*a,
Shigeyuki Aomi, MDa,
Hiroshi Nishida, MDa,
Masahiro Endo, MDa,
Hitoshi Koyanagi, MDa
a Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
Accepted for publication November 20, 2000.
* Address reprint requests to Dr Tsukui, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, 8-1 Kawada, Shinjuku, Tokyo 162-8666, Japan
e-mail: htsukui{at}jasmine.ocn.ne.jp
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Abstract
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Coronary ostial stenosis between an interposition graft and coronary artery is rare and fatal. A 46-year-old woman who had reconstruction of both coronary arteries using interposition grafts for type A acute dissecting aneurysm presented with acute chest pain. Emergent coronary artery bypass grafting was done with saphenous vein grafts. Inappropriate use of gelatin-resorcinol-formaldehyde glue can be associated with ostial stenosis in the long term. Transesophageal echocardiography is useful to diagnose ostial stenosis of the coronary arteries.
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Introduction
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Gelatin-resorcinol-formaldehyde (GRF) glue was first used to treat aortic dissection in 1979 by Guilmet and colleagues [1] and improved patient survival rates [2]. However, questions remained about possible toxic effects because of the presence of formaldehyde. Some long-term problems concerning GRF glue have been reported [3–5]; therefore, care should be taken to prevent its possible adverse effects.
A 46-year-old woman with Marfan syndrome presented with acute chest pain. At 34 years of age, she had had graft replacement of the descending thoracic aorta for DeBakey type IIIB dissecting aneurysm. At age 46 years, she was diagnosed with annuloaortic ectasia and acute type A dissecting aneurysm extending to the bilateral coronary ostia. Emergent Bentall type operation with total arch replacement was done. Both coronary arteries were reconstructed using interposition graft technique with a small woven Dacron graft. The false lumen of both coronary arteries was closed with GRF glue. T1 scintigraphy, electrocardiography, and transesophageal echocardiography (TEE) showed no abnormalities, but coronary angiography to check the graft patency was not done before discharge. She was readmitted to our institute with severe chest pain 8 months later. Electrocardiography showed ST depression in II, III, aVF, V5, and V6 leads. Creatine kinase was elevated to 418 IU/L. Her TEE showed accelerated blood flow of the anastomosis between the left interposition graft and the left coronary artery (Fig 1). Cardiac catheterization showed 99% and 90% stenosis between the interposition grafts and left and right coronary arteries, respectively (Fig 2). We decided to perform emergent coronary artery bypass grafting.
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Fig 1. Transesophageal echocardiography. Top, Accelerated blood flow between the interposition graft and the left coronary artery. (A = anastomosis site of interposition graft and left coronary artery; B = left anterior descending coronary artery; I = interposition graft. Bottom, Doppler evaluation of accelerated blood flow.) Left, Velocity at A (anastomosis site of interposition graft and the left coronary artery) was 3.0 m/s. Right, Velocity at B (left anterior descending coronary artery) was 1.5 m/s.
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Fig 2. Preoperative cardiac catheterization. Ninety-nine percent and 90% stenoses were demonstrated between the interposition grafts and the left main trunk (LMT, white arrow) and the right coronary artery (RCA, black arrow), respectively.
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Median resternotomy was done carefully. Cardiopulmonary bypass was established with ascending grafting and right atrial cannulation with a pulmonary vein vent. At the ascending graft, aortic clamping and cardioplegia were used. Coronary artery bypass grafting was done with saphenous vein grafts between the proximal portion of the left anterior descending coronary artery, proximal portion of the right coronary artery, and the ascending graft. Postoperative catheterization showed patency of both bypass grafts (Fig 3). ST elevation in the electrocardiogram disappeared. The patient was discharged uneventfully and has been well for 3 months.
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Fig 3. Postoperative cardiac catheterization. Saphenous vein grafts (SVG) between the proximal portion of the right coronary artery (RCA), left anterior descending coronary artery (LAD) and the ascending graft were patent.
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Comment
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Ostial stenosis of a coronary artery after a Bentall type operation is rarely reported but has fatal results. One case of right ostial stenosis 6 months after a Carrel patch method using GRF glue was reported by Kiyama and associates [3]. The authors suspected that marked progression of stenosis occurred in association with injection of GRF glue into the dissected space.
To diagnose ostial stenosis of the coronary arteries without cardiac catheterization is difficult. Transesophageal echocardiography provides useful information on coronary blood flow to enable prompt and less invasive diagnosis. Especially in patients with an artificial valve or history of graft replacement, TEE is preferable to avoid infection.
Gelatin-resorcinol-formaldehyde glue has excellent hemostatic characteristics and is widely used for dissecting aneurysm; however, some problems concerning GRF glue have been reported. Fukunaga and associates [4] reported nine cases of aortic root redissection after reconstruction of dissecting aneurysms using GRF glue. They considered that the complications were likely to be caused by the toxic effects of formaldehyde, particularly in cases where an excessive amount of formaldehyde was present that was not chemically bound to resorcin. Coronary ostial stenosis after complete replacement of the aortic root and reimplantation of the coronary arteries was observed in several circumstances in which no GRF glue was used. It might be related to the suture technique at the coronary ostium, particularly if a small Dacron graft is used for reimplantation. In our case, it is conceivable that ostial stenosis occurred as a result of inappropriate use of GRF glue rather than a technical problem, because T1 scintigraphy, electrocardiography, and TEE showed no abnormalities on discharge and it occurred bilaterally and simultaneously. Bingley and associates [5] reported that some months to years after the initial use of GRF glue, tissues were extremely fibrosed at the site of glue application, and a number of patients had redissection of the aortic root where GRF glue had been applied. In our case, an excessive amount of formaldehyde could have induced bilateral ostial stenosis of the coronary arteries owing to redissection of the coronary ostia accompanied by fibrosis at the site of glue application; however, it is impossible to verify the adverse effects of the formaldehyde because histologic examination was not done. Bachet and associates [2] recommended that as few as two or three droplets of formaldehyde are sufficient to polymerize 1 mL of gelatin resorcinol mixture. To avoid ostial stenosis, the glue is injected between the dissected layers, with special care directed not to contaminate the coronary ostia. A few drops of formaldehyde are then added to the glue by using a cannula-tipped syringe. Thereafter, the layers should be compressed to improve the polymerization process.
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Acknowledgments
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The authors thank Naoko Ishizuka, MD, Department of Cardiology, The Heart Institute of Japan, Tokyo Women’s Medical University, for her skillful evaluation of echocardiography.
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References
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Guilmet D., Bachet J., Goudot B., et al. Use of biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 1979;77:516-521.[Abstract]
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Bachet J., Goudot B., Dreyfus G., et al. The proper use of glue: a 20-year experience with the GRF glue in acute aortic dissection. J Cardiac Surg 1997;12:243-253.[Medline]
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Kiyama H., Ohshima N., Sakurada M., et al. A case of progressive right coronary ostial stenosis after Carrel patch method using gelatin-resorcin-formalin glue. Kyobu Geka 1998;51:102-105.[Medline]
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Fukunaga S., Karck M., Harringer W., et al. The use of gelatin-resorcin-formalin glue in acute aortic dissection type A. Eur J Cardiothorac Surg 1999;15:564-570.[Abstract/Free Full Text]
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Bingley J.A., Gardner M.A.H., Stafford E.G., et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg 2000;69:1764-1768.[Abstract/Free Full Text]
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Abstract
Introduction
