J Thorac Cardiovasc Surg 2006;131:761-762
© 2006 The American Association for Thoracic Surgery
Mechanical aortic valve malfunction: An intraoperative BioGlue complication
Frank A. Baciewicz, Jr, MD
Department of Cardiothoracic Surgery, Wayne State University, School of Medicine, Detroit, Mich
To the Editor:
I read "Mechanical Aortic Valve Malfunction: An Intraoperative BioGlue Complication" by Karimi and associates. The communication reports that BioGlue (Cryolife Inc, Kennesaw, Ga) can migrate through the aortotomy suture line. It was interesting that there was an interval after the glue was applied to the suture line but before it migrated through to cause the mechanical valve incompetence (demonstrated by the altered function of the prosthetic valve on transesophageal echocardiography). Also of concern was the fact that the BioGlue migrated through 4-0 suture holes rather than a defect in the aortotomy closure.
I recently performed repair of a type I aortic dissection with ascending aorta and hemic-arch replacement and with resuspension of the aortic valve. The patient had been treated with heparin, clopidogrel, and aspirin after admission because of an assumed diagnosis of myocardial infarction. After the patient was separated from cardiopulmonary bypass, with protamine, fresh-frozen plasma, and platelets having been administered, there was still oozing from the suture line. A thin layer of BioGlue was applied, with cessation of the bleeding. The patient had a cardiac output of 7 L and excellent intraoperative myocardial function.
Forty-five minutes after return to the intensive care unit, the patient became hypotensive, with a 1-mm increase of the lateral electrocardiogram lead. There was minimal output through the chest tubes, but because the patient was unresponsive to inotropes, the chest was opened. The patient was resuscitated with open massage. After several minutes of open massage and intracardiac epinephrine, the patient had normal blood pressure and no electrocardiogram changes. His cardiac output was more than 5 L without inotropic support. There was no bleeding from the suture lines.
After reading this communication, my suspicion is that the BioGlue application to the anterior part of the aortic root suture line migrated through the suture line and embolized the coronary arteries after the patient returned to the intensive care unit. Other possibilities include air or tissue embolus or localized redissection in the proximal root.
I would recommend the use of BioGlue on suture lines only to achieve hemostasis and would use only a minimal amount of the adhesive.
