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Ann Thorac Surg 2006;81:1499-1500
© 2006 The Society of Thoracic Surgeons

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Case report

Acute Intraoperative Malfunction of Aortic Valve Due to Surgical Glue

Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, United Kingdom

Accepted for publication March 1, 2005.

^_* Address correspondence to Dr Devbhandari, Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Whinney Hey's Rd, Blackpool, FY3 8NR United Kingdom (Email: sdevbhandari{at}aol.com).

	Abstract

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The use of surgical glues in aortic surgery has gained wide popularity due to their hemostatic and tissue reinforcing properties. Reports of acute complications associated with application of glue are rare. We report the case of a 52-year-old fragile, steroid-dependent woman who developed acute intraoperative dysfunction of an aortic prosthetic valve due to use of BioGlue surgical adhesive. A brief literature review of the acute and long-term complications of the glue is presented.

	Introduction

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A variety of glues have been marketed since the gelatin resorcinol formol (GRF) glue was first popularized by Jean Bachet. Their use in hemostasis and tissue strengthening are well established. Although their long-term complications are fairly well recognized, the reports of acute intraoperative complications are rare. We report the case of a patient who developed acute intraoperative malfunction of the prosthetic valve due to use of the glue, which was difficult to recognize. We suggest a way to avoid this complication in the future.

A 52-year-old woman was referred from a district hospital with features of congestive cardiac failure due to mixed aortic valve disease. Her significant past history included bilateral mastectomies for carcinoma of the breast (3 and 7 years earlier) and Hodgkin's disease in childhood treated with chemotherapy and radiotherapy. She had no features suggestive of recurrence of any of these malignancies. She had no history of angina or syncopal attacks. The aortic valve had a mean gradient of 80 mm Hg associated with severe regurgitation. The coronary arteries were normal.

She underwent urgent aortic valve replacement using antegrade cold blood cardioplegia. A trans-mitral left ventricular vent was used through the right superior pulmonary vein. The aortic root was small and the valve was severely calcified. The aortic valve was excised followed by enlargement of the aortic root using a patch of Hemashield (Boston Scientific Co, Galway, Ireland). The aortic valve was replaced with a size 19-mm Sorin Slimline mechanical prosthesis (Sorin Biomedica, Saluggia, Italy) using 2-0 Ethibond (Ethicon Ltd, Edinburgh, UK) pledgeted stitches. The aorta was closed using the Hemashield patch (Boston Scientific Co) with two running sutures of 4-0 Prolene (Ethicon, Somerville, NJ). BioGlue (CryoLife International Inc, Kennesaw, GA) was used to seal the suture line.

During weaning from cardiopulmonary bypass, the heart was distended with a severe rise in pulmonary artery pressure. Bypass resumed followed by a transesophageal echocardiogram. However, this was unhelpful as only a poor view of the aortic prosthesis was obtained. A second attempt at weaning from bypass failed. It was felt that the relatively large prosthesis might be impinging on the coronary ostia in the small aortic root. Two bypass grafts were performed to the left anterior descending artery and right coronary artery using the saphenous vein. A further attempt at weaning from bypass failed. At this point it was decided to inspect the aortic prosthesis. The aortic root was opened through the Hemashield patch (Boston Scientific Co). We were surprised to find that the BioGlue had been sucked inside the aorta through the suture holes and had actually jammed the valve leaflets. The glue was removed and the valve worked satisfactorily. Subsequently the patient was weaned from bypass with the aid of inotropes and an intraaortic balloon pump. The patient then made a slow but uneventful recovery and was discharged home 12 days after the operation.

She presented again a year later with marked dyspnea and features of constrictive pericarditis, which required a formal pericardiectomy with good results. Sadly she died 2 years later due to intestinal obstruction and perforation peritonitis secondary to carcinomatosis peritonei from recurrent breast cancer.

	Comment

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A variety of surgical glues are available. Most experience is with the GRF glue, but concerns about the potential toxic effects of the formaldehyde component have led to a decline in its use. BioGlue consists of 10% glutaraldehyde and 45% bovine serum albumin solution. The exposure of bovine serum albumin, extra cellular matrix, and cell surfaces to the glutaraldehyde component cause their lysine molecules to bind to each other, which starts a complex polymerization resulting in a strong scaffold.

Glues have an established role in supporting suture lines for hemostasis, reinforcing fragile tissue, and adhering dissected tissue planes [1]. Reported long-term complications of glue include pseudo aneurysm, re-dissection [2], anastomotic stricture [3], and coronary ostial stenosis [4].

There are few reports of acute complications with the use of glues. Acute embolization of GRF glue into the cerebral circulation [5] and coronary arteries [6] have been reported with fatal outcomes. Lemaire and colleagues [7] have reported a case of phrenic nerve paralysis with the BioGlue (CryoLife International Inc). There has been only one previous report of acute dysfunction of a mechanical valve due to application of GRF glue [8] in a patient with a fragile aorta during a redo aortic valve replacement. In that case, transthoracic echocardiogram performed after failed weaning from bypass showed a large unrecognizable tissue density mass in the aorta in place of the mechanical bi-leaflet valve. On opening the aorta, the valve was found to be encased by a gelfoam-like material with a thrombin clot in the aorta. Replacement with a fresh prosthesis and closure without glue led to a successful outcome.

The important lesson from this case is that extreme care is required while applying glue in an aortic repair. Only a thin bead of glue should be used, just sufficient to cover the anastomotic area. Vigorous negative pressure suction inside the aortic root while the glue is being applied may lead to entraining of the glue into the aortic lumen. It is advisable to stop the suction on the left ventricular vent during this part of the procedure. Other usual precautions, such as drying tissue surfaces and allowing time for polymerization should be observed.

In conclusion, although surgical glue is very helpful in achieving hemostasis and strengthening fragile tissue, extreme care is required in its application. Negative suction inside the aorta should be avoided when glue is applied to the aortic suture line.

	References

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1. Passage J, Jalali H, Tam RKW, Harrocks S, O'Brien MF. BioGlue surgical adhesive—an appraisal of its indications in cardiac surgery Ann Thorac Surg 2002;74:432-437.[Abstract/Free Full Text]
2. Bingley JA, Gardner MAH, Stafford G, et al. Late complications of tissue glues in aortic surgery Ann Thorac Surg 2000;69:1764-1768.[Abstract/Free Full Text]
3. Lemaire SA, Schmittling ZC, Coselli JS, et al. BioGlue surgical adhesive impairs aortic growth and causes anastomotic strictures Ann Thorac Surg 2002;73:1500-1506.[Abstract/Free Full Text]
4. Tsukui H, Aomi S, Hishida H, Endo M, Koyanagi H. Ostial stenosis of coronary arteries after complete replacement of aortic root using gelatine-resorcinol-formaldehyde glue Ann Thorac Surg 2001;72:1733-1735.[Abstract/Free Full Text]
5. Carrel T, Maurer M, Tkebuchava T, et al. Embolization of biologic glue during repair of aortic dissection Ann Thorac Surg 1995;60:1118-1120.[Abstract/Free Full Text]
6. Mahmood Z, Cook DS, Luckraz H, O'Keefe P. Fatal right ventricular infarction caused by Bioglue coronary embolism J Thorac Cardiovasc Surg 2004;128:770-771.[Free Full Text]
7. Lemaire SA, Schmittling ZC, Undar A, et al. A new surgical adhesive (BioGlue) causes acute phrenic nerve injury and diaphragmatic paralysis J Surg Res 2000;93:354.
8. Gillham MJ, Tousignant CP. Diagnosis by intra-operative trans-esophageal echocardiography of acute thrombosis of mechanical aortic valve prosthesis associated with the use of biological glue Anesth Analg 2001;92:1627-1629.

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This Article Abstract Full Text (PDF) 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): Mohan P. Devbhandari Andrew J. Duncan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Devbhandari, M. P. Articles by Duncan, A. J. Search for Related Content PubMed PubMed Citation Articles by Devbhandari, M. P. Articles by Duncan, A. J. Related Collections Valve disease