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J Thorac Cardiovasc Surg 2004;127:1819-1821
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Department of Cardiac Surgery, Metropolitan Hospital, North Faliro, Greece,
b Department of Radiology, University of Athens Medical School, Athens, Greece.
Received for publication November 29, 2003; accepted for publication December 16, 2003.
* Address for reprints: George C. Economopoulos, MD, Director, Cardiac Surgery, Metropolitan Hospital, 9 E Makariou and 1 E Venizelou Sts, Neo Faliro 18547, Greece
geconomo{at}otenet.gr
We report a case of superior vena cava (SVC) stenosis with upper body venous hypertension after application of biologic glue in the vicinity of the SVC after a double valve replacement and an annuloplasty procedure. The SVC stenosis was managed successfully with balloon dilatation and stent placement.
Clinical summary
A 63-year-old man was scheduled for double (aortic and mitral) valve replacement and tricuspid valve annuloplasty. Bicaval cannulation was performed through the right atrial appendage for the SVC and the atriocaval junction for the inferior vena cava; standard ascending aortic cannulation was also performed. Antegrade and retrograde cold blood cardioplegia with moderate core hypothermia (30°C) constituted the cardioprotective strategy. The exposure of mitral and tricuspid valves was obtained through a superior transseptal approach; exposure of the aortic valve was obtained through a transverse aortotomy. After the mitral and the aortic valve replacements, a DeVega tricuspid valve annuloplasty, and closure of the atriotomy incision, there was persistent bleeding from the dome of the left atrium. Despite adequate suturing, local sponge packing, reversal of all anticoagulants, and plasma and platelet transfusions, the oozing persisted. A fair amount of BioGlue (Cryolife, Inc, Kennesaw, Ga) was placed on the area, with a successful result. The patient had an uneventful recovery, and he was discharged on the ninth postoperative day.
The patient returned 8 months later, reporting headaches, dizziness especially on bending, and significant swelling of the face and neck. Echocardiography revealed a competent tricuspid valve repair and two well-functioning artificial valves, with satisfactory myocardial performance. A retroaortic and paracaval echodense mass was noted to be compressing the SVC at its junction with the right atrium (Figure 1). An upper-body venogram revealed a severe stenosis (>90%) of the SVC (Figure 2, A). Dilatation of the SVC with 7-mm and 12-mm balloons, followed by placement of a 12 x 64-mm Wallstent (Boston Scientific, Watertown, Mass), successfully relieved the stenosis (Figure 2, B). The patient is doing well without recurrent stenosis 16 months after the procedure.
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After the adverse effects of cyanoacrylate-based glue on the aortic tissues became apparent,1-3 a new bovine albumin–based glue cross-linked with glutaraldehyde, BioGlue, was introduced into the cardiac surgical market as the new, nontoxic glue for hemostasis. The product is a preparation of bovine albumin cross-linked with glutaraldehyde to form a strong adhesive bond. It is supplied in a two-barrel applicator; the two compartments contain albumin and glutaraldehyde, which are mixed at the time of application. After mixture, the glue solidifies in about 30 seconds and achieves maximum strength in about 2 to 3 minutes.4 The use of BioGlue in aortic surgery was met with great initial enthusiasm, because not only did it increase the strength of the friable aortic walls in aortic dissection when it was applied between the dissected aortic layers, it was proved effective as a sealing agent at the anastomotic suture line.5-8
Recently, experimental and clinical studies have reported on local tissue damage, local inflammatory response, and risk of pseudoaneurysm formation and great vessel stenosis when BioGlue is applied circumferentially, especially in the pediatric population.9 In experiments with piglets, LeMaire and associates10 discovered that when BioGlue was applied circumferentially around aortoaortic anastomoses, it impaired vascular growth and caused anastomotic strictures. In our case we believe that an inappropriately large amount of BioGlue was placed between the roof of the left atrium, the adjacent superior cavoatrial junction, and the aortic root. The initially liquid glue, helped by gravity, encircled the cavoatrial junction. After it solidified, it caused the stricture with time.
We believe that BioGlue should be applied sparingly, avoiding spillage, because when the glue is still liquid it may gravitate to dependent, not easily visible areas. Thus it may surround and damage vascular or neuronal tissues, or even compress and constrict low-pressure vascular structures, when it solidifies.
References
This article has been cited by other articles:
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  G. Dimitrakakis and U. O. von Oppell The use of biological glues in cardiothoracic surgery Interact CardioVasc Thorac Surg, August 1, 2011; 13(2): 118 - 118. [Full Text] [PDF]
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 K. J. Zehr Use of Bovine Albumin-Glutaraldehyde Glue in Cardiovascular Surgery Ann. Thorac. Surg., September 1, 2007; 84(3): 1048 - 1052. [Abstract] [Full Text] [PDF]
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 A. Malik, M. Oc, G. Doukas, C. Alexiou, and T. J. Spyt Early Failure of Surgical Angioplasty with Tissue Glue: A Word of Caution Asian Cardiovascular and Thoracic Annals, October 1, 2006; 14(5): e91 - e92. [Abstract] [Full Text] [PDF]
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S. Downing INVITED COMMENTARY Ann. Thorac. Surg., May 1, 2005; 79(5): 1529 - 1529. [Full Text] [PDF]
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