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Case Reports

Mechanical Aortic Valve Dysfunction Due to Biological Glue

Division of Pediatric Cardiothoracic Surgery, The Children's Hospital, Denver, Aurora, Colorado

Accepted for publication December 15, 2008.

^_* Address correspondence to Dr Goldberg, Pediatric Cardiac Surgery, The Children's Hospital, 13123 E 16th Ave, B200, Aurora, CO 80045 (Email: sgoldberg17{at}yahoo.com).

	Abstract

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We report a case of mechanical aortic valve replacement that was complicated by acute occlusion of one of the valve leaflets by the BioGlue (CryoLife Inc, Kennesaw, GA) that had seeped through the suture line on the aorta. This uncommon, but life-threatening complication is one that may go unrecognized, but is preventable.

	Introduction

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Biological glue sealants have become invaluable adjuncts to surgical hemostasis, especially in multiple and complex suture lines. There have been scattered reports of complications arising from embolization of glue particles or seepage through suture lines. If this happens in the setting of mechanical valve replacement, the action of glue sealants on the valve leaflets themselves can have catastrophic results. We report one such case of abrupt dysfunction of a mechanical aortic valve from biological glue.

A 13-year-old boy was admitted to our service after a cardiac arrest while playing vigorous basketball. He had a history of aortic stenosis and mitral regurgitation, and he had undergone balloon valvuloplasty of his aortic valve as a newborn. During the ensuing years he underwent multiple operations, including three aortic valve repairs and one mitral valve repair, culminating in the replacement of his aortic valve 3 years prior to this event with a 21-mm bovine pericardial valve. After his resuscitation, his echocardiogram demonstrated a mitral regurgitant velocity of 6 m/sec, and a mean left ventricular outflow tract gradient of 50 mm Hg (peak gradient, 80 mm Hg). He recovered from his arrest with normal neurologic function. It was decided that both valves should be replaced with mechanical prostheses, given the number of sternotomies he had already had undergone.

The mitral valve was replaced first, using a 29-mm mechanical valve (ATS, Minneapolis, MN). After opening the prior aortotomy, it was evident that a Manougian annular enlargement procedure had been done for the prior aortic valve replacement. We re-did the Manougian with a Gore-Tex patch (W. L. Gore & Assoc, Flagstaff, AZ), but were unable to fit a 22-mm valve in the aortic position. This necessitated performing a Konno aorto-ventriculoplasty to be able to safely fit a 24-mm ATS valve. The Konno was completed with a two-patch technique, including the ascending aorta. The suture line was then reinforced with BioGlue (CryoLife Inc, Kennesaw, GA). The patient separated from cardiopulmonary bypass without difficulty and was returned to the intensive care unit in satisfactory condition.

The following morning, there was concern for an immobile leaflet of the aortic prosthesis due to the routine chest roentgenogram results in the intensive care unit. This was subsequently confirmed by fluoroscopy, and the patient was immediately returned to the operating room. After institution of cardiopulmonary bypass and cardioplegic arrest, the Gore-Tex patch (W. L. Gore & Assoc) on the ascending aorta was opened in the middle to inspect the valve; it was readily apparent that a small amount of BioGlue had sealed one disk of the valve to the ring, fixing it in the closed position. It appeared that the glue had seeped through the aortotomy suture line and dripped onto the valve, anchoring that leaflet in position. We peeled the glue off the valve, irrigated the area copiously, and restored normal leaflet motion. The patch was closed and the patient was separated from cardiopulmonary bypass. Intraoperative transesophageal echocardiography was unable to obtain clear identification of the valve leaflets earlier, so an epicardial ultrasound was performed, but again, reliable images of the leaflet mobility were unable to be obtained. We transported the patient to the adjacent cardiac catheterization suite for fluoroscopic examination of the valve, which demonstrated good leaflet mobility. Postoperatively, the patient suffered a mild cerebrovascular accident from which he has fully recovered; subsequently, he underwent placement of an internal defibrillator as a precautionary measure.

	Comment

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Intraoperative occlusion or dysfunction of valve prostheses as a result of biological glues and sealants has been infrequently reported in the literature, but the results can often be catastrophic. In 2001, Gillham and Tousignant [1] reported an acute thrombosis of a mechanical aortic valve from gelatin-reorcin-formaldehyde-gluteraldehyde glue. In their case, the patient was unable to separate from cardiopulmonary bypass despite inotropic support and the use of intra-aortic balloon counterpulsation. The valve dysfunction was recognized on intraoperative transesophageal echocardiography and the aorta was re-opened at the time of the original operation [1]. Subsequent case reports have also described discovering this phenomenon intraoperatively at the original surgery, including one involving BioGlue [2], and one involving Tisseal (Baxter Healthcare, Deerfield, IL) [3]. In a detailed in vitro study, the groups from Houston analyzed the incidence of BioGlue seepage through suture lines in various prosthetic graft materials, as well as fresh porcine aorta, and found that the glue leaked through 10% (18 of 180) of anastomoses. The authors made several recommendations toward prevention, including (1) only applying the glue after attainment of secure hemostasis, (2) slow release of the glue to increase its initial viscosity and hopefully minimize entry into needle holes, and (3) stopping the suction on left ventricular vents to reduce actively sucking liquid glue through the suture line [4].

In this case report, we hope to shed light on a problem that can be easily prevented, but if left unrecognized it can create significant morbidity and mortality. The previous reports have described intraoperative discovery of the problem based on transesophageal echocardiography, which can not always render accurate images of the mechanical disks in motion, as in our case. Our patient's valve dysfunction was recognized a day later, necessitating a return to the operating room. During that time, there is a risk of myocardial damage from left ventricular outflow tract obstruction, as well as systemic embolization of glue particles. The application of BioGlue (CryoLife Inc) and other surgical sealants to all areas of cardiothoracic surgery has been of inestimable value in securing hemostasis in complex suture lines, and should continue to be extensively used, but with careful attention to potential complications.

	References

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1. Gillham MJ, Tousignant CP. Diagnosis by intraoperative transesophageal echocardiography of acute thrombosis of mechanical aortic valve prosthesis associated with the use of biological glue Anesth Analg 2001;92:1123-1125.[Free Full Text]
2. Devbhandari MP, Chaudhery Q, Duncan AJ. Acute intraoperative malfunction of aortic valve due to surgical glue Ann Thorac Surg 2006;81:1499-1500.[Abstract/Free Full Text]
3. Birmingham B. TEE diagnosis of mechanical AVR dysfunction associated with biological glue Anesth Analg 2001;93:1627-1628.[Free Full Text]
4. LeMaire SA, Carter SA, Won T, Wang X, Conklin LD, Codelli JS. The threat of adhesive embolization: BioGlue leaks through needle holes in aortic tissue and prosthetic grafts Ann Thorac Surg 2005;80:106-111.[Abstract/Free Full Text]

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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): Steven P. Goldberg David N. Campbell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goldberg, S. P. Articles by Campbell, D. N. Search for Related Content PubMed PubMed Citation Articles by Goldberg, S. P. Articles by Campbell, D. N. Related Collections Valve disease