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Ann Thorac Surg 2002;74:295-296
© 2002 The Society of Thoracic Surgeons

Correspondence

Reply

Martin H. McMullan, MDa, Michael D. Maples, MDa

a The Cardiovascular Surgical Clinic, P.A., 501 Marshall St, Suite 100, Jackson, MS 39202, USA

e-mail: cvsc{at}ucmail.com

To the Editor

The suggestion by Totaro and Minzioni regarding the use of BioGlue surgical adhesive combined with bovine pericardium in the treatment of left ventricular free wall rupture seems an excellent idea. We have used BioGlue for dissecting aneurysms and think it has enhanced our surgical technique considerably. However, in the United States, BioGlue is still under an investigational designation requiring institutional review board approval for its use in any hospital. Furthermore, it is approved by the Food and Drug Administration only for use in dissecting aneurysms. One must recognize that to use BioGlue off-label may raise legal issues. It is also true that use of an unapproved product like Krazy Glue (Elmer’s Products, Inc, Columbus, OH) raises these same legal issues.

BioGlue costs a hospital approximately $600 per application as opposed to Krazy Glue, which costs approximately $3 per tube at a retail store. This cost differential is certainly significant, and our experience would indicate there is no difference in the utility of these two products in this setting.

We recently have seen another patient with left ventricular free wall rupture of the "blow-out" type, patient 21 in our series. The patient was a previously robust 77-year-old man who experienced an anterior myocardial infarction on August 7, 2001. He was treated with lytic therapy with evidence of reperfusion. The following day he underwent cardiac catheterization. He was found to have severe anterior akinesis and apical dyskinesis, a 95% residual proximal left anterior descending coronary artery stenosis, and an 80% proximal right coronary artery stenosis. His condition was stabilized, and he was to undergo viability studies and echocardiography in a few days.

On August 13, while undergoing echocardiography, the patient was found to have a large pericardial effusion with evidence of tamponade. At the beginning of the study, he was asymptomatic but rapidly became hypotensive and pale and subsequently had a seizure. A diagnosis of left ventricular free wall rupture was made. We raced to the operating room with the patient without intubation or external massage because he still had a femoral pulse and respiratory effort. Simultaneously intubation was performed and femoral-femoral bypass established within 20 minutes of the development of cardiogenic shock. Once the patient was on femoral-femoral bypass, we proceeded with median sternotomy, right and left anterior descending coronary artery bypass grafting using saphenous vein graft, and repair of a 2-cm linear rupture in the anterior apical segment of the left ventricle using the patch-and-glue technique (Krazy Glue and bovine pericardium) after first approximating the edges with large mattress sutures of 3-0 polypropylene backed with felt pledgets. We inserted an intraaortic balloon assist device to facilitate discontinuation of bypass and because of our experience in the past with rerupture. The patient is doing well with no organ deficit. It appears he will be a long-term survivor.

The case of this patient further amplifies our philosophy of treatment of left ventricular free wall rupture to include the following:

  1. A high index of suspicion that leads to rapid echocardiography in any patient with hemodynamic deterioration who has recently sustained a myocardial infarction.
  2. Conveyance of the patient to the operating room as quickly as possible, even if he or she is being resuscitated, to establish femoral-femoral bypass (avoiding any delay to attempt pericardiocentesis, intraaortic balloon pump insertion, or femoral-femoral bypass in anywhere other than the operating room).
  3. Use of the patch-and-glue technique to cover the entire area of infarction to prevent rerupture and minimize alterations in left ventricular geometry.


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Ann. Thorac. Surg. 2002 74: 294. [Extract] [Full Text] [PDF]




This Article
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Michael D. Maples
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