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J Thorac Cardiovasc Surg 2005;129:937-938
© 2005 The American Association for Thoracic Surgery
Brief Communications |
a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
b Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn
c Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
Received for publication July 16, 2004; accepted for publication July 21, 2004. * Address for reprints: Thoralf M. Sundt, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (E-mail: sundt.thoralf{at}mayo.edu).
Postoperative hemorrhage remains a significant cause of mortality and morbidity after repair of acute aortic dissection. Accordingly, there has been great interest in the development and application of biologic hemostatic tissue sealants for use during this and other aortic surgical procedures.1 Among these agents, BioGlue (Cryolife, Inc, Kennesaw, Ga) appears remarkably effective and has rapidly gained wide acceptance.1,2 However, because it is composed of 45% (wt/vol) purified bovine albumin and 10% (wt/vol) glutaraldehyde in a 4:1 ratio, we have been concerned that it might not be completely innocuous. We have recently encountered a case of late anastomotic pseudoaneurysm potentially related to the use of BioGlue.
Clinical summary
During cardiologic evaluation of recurrent atrial flutter, a 76-year-old man was found to have a pseudoaneurysm of the ascending aorta. Two years previously, he had an acute type A dissection, for which he underwent graft replacement of the ascending aorta and hemiarch, as well as bioprosthetic aortic valve replacement, at another institution. In addition, he had a stable 3.1-cm abdominal aortic aneurysm, chronic obstructive pulmonary disease, history of seizure disorder, and recurrent atrial tachyarrhythmia for which catheter ablation and electrical cardioversion had been performed.
Transthoracic echocardiography demonstrated normal left ventricular (LV) function, mild-to-moderate mitral regurgitation, moderate aortic periprosthetic regurgitation, grade 3/4 LV diastolic dysfunction consistent with severely increased LV filling pressure, and a dilated ascending aorta. Computed tomography with 3-dimensional reconstruction performed to evaluate the aorta (Figure 1) demonstrated an ascending aortic pseudoaneurysm, although the entry site could not be identified. Coronary angiography and aortography, respectively, revealed normal coronary arteries and a pseudoaneurysm of the ascending aorta with what appeared to be entry sites both proximally and distally.
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Both proximal and distal suture lines were almost circumferentially disrupted, and the aortic cuff appeared soft and friable. Persistent concretions of BioGlue were identified between the aortic layers. The previous graft was excised in its entirety, and the cuff of the native aortic tissue was debrided of all visible traces of BioGlue. Microscopy of resected aortic tissue revealed focal adventitial fibrosis, degenerating thrombus, amorphous biologic glue, and focal acute and chronic nongranulomatous inflammation (Figure 2).
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Discussion
Biologic adhesive hemostatic sealants facilitate cardiac surgical procedures and are particularly useful in cases in which the proclivity for bleeding is high.1 Various biologic glues have been used in cardiac surgery for more than 2 decades.2 Despite initial enthusiasm, late complications directly related to their use have become apparent with time.3
Our experience raises concern about the potentially harmful effects of BioGlue to local tissue. It has been our anecdotal observation during reoperation on patients in whom large quantities of BioGlue appear to have been used that the substance persists and that surrounding tissues are soft and friable. The results of histologic study in the current case demonstrate an ongoing local inflammatory process 2 years after application, indicating that BioGlue might retard normal healing. This substance has previously been shown to impair tissue growth and cause stricture formation in some circumstances4 and has been shown to lead to tissue necrosis.5 These changes in structural integrity might weaken the tissues and predispose to late complications, such as pseudoaneurysm formation, as has been previously suggested.6
Prior experience with other biologic glues3,5 might now evoke a sense of déjà vu with BioGlue. There is no question that the benefits of such agents in controlling blood loss in cardiac surgery might be truly life-saving in some circumstances. Nevertheless, their use should be parsimonious, and glues should not be considered substitutes for sutures and fastidious surgical hemostasis.
References
This article has been cited by other articles:
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  K. J. Zehr Reply. Ann. Thorac. Surg., September 1, 2008; 86(3): 1056 - 1057. [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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 G. J. Van Nooten, P. Somers, R. Forsyth, K. Narine, Y. Van Belleghem, S. Jacobs, and F. De Somer Autologous glue: Part of the sticky mystery unraveled J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 415 - 423. [Abstract] [Full Text] [PDF]
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S. A. LeMaire Invited commentary Ann. Thorac. Surg., May 1, 2007; 83(5): 1626 - 1627. [Full Text] [PDF]
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S. Haj-Yahia, T. Mittal, E. Birks, M. Carby, M. Petrou, J. Pepper, G. Dreyfus, and M. Amrani Lung fibrosis as a potential complication of the hemostatic tissue sealant, biologic glue (Bioglue) J. Thorac. Cardiovasc. Surg., May 1, 2007; 133(5): 1387 - 1388. [Full Text] [PDF]
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