J Thorac Cardiovasc Surg 2002;123:1015-1016
© 2002 The American Association for Thoracic Surgery
Reply to the Editor:
Francesco Alamanni, MD,
Alessandro Parolari, MD, PhD,
Paolo Biglioli, MD
Department of Cardiac Surgery, University of Milan, Centro Cardiologico Fondazione, Monzino IRCCS, Via Parea, 4, Milan, Italy
We appreciate the comments by Galajda, Fülöp, and Péterffy regarding our manuscript on the use of surgical glues for the treatment of postinfarction subacute rupture of the left free wall. Their case report lends further credence to our view that glues are a valuable tool in the management of these difficult complications. They should also be congratulated for the successful management of such a difficult case. However, we would like to point out that their approach was substantially different from the one we propose. Their main strategy was to close multiple defects with stitches over polytetrafluoroethylene strips on a beating heart. Such stitches quite often can tear through the ventricle and increase the size of the defects. In addition, we can suppose that the external (epicardial) patch with fibrin glue was most likely applied once hemostasis was totally secured as a completion of the procedure. In fact, in the case of left free wall rupture, it is almost impossible to achieve a bloodless field on a beating, even if adequately vented, heart, and the washing of glue from the blood oozing from the ventricle cannot be avoided.
In case of left free wall ruptures still actively bleeding or oozing, we propose the following:
- Avoid deep stitching of the left ventricle, as it could increase the size of the defect(s) to be repaired; only a few epicardial stitches can be gently applied far away from the area of the defect to improve subsequent positioning of the patch (sail-like)
- Clamp the aorta, arrest the heart with cardioplegic solution, and vent the heart
- Obtain a completely bloodless field, and then apply a glue with an extremely high adhesive power, which will both fix and stabilize the frail ventricular area around the defect and secure good adhesion of the first patch to the ventricle
- Then proceed with the application of the second patch with a more elastic glue to reduce stress on the first patch Finally, a different approach can be chosen when there is no active bleeding from the defect; in this case glues and patches can be applied on the actively beating heart. Recently we used this technique for an iatrogenic (after an electrophysiologic study) S-shaped tear in the free wall of the right ventricle causing tamponade, in which case active bleeding had already stopped at the time of surgery.
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