Blockage of a Mechanical Aortic Valve Leaflet with BioGlue: A Case Report

Abstract

Mechanical aortic valve dysfunction is a very rare event and is usually due to thrombosis, pannus overgrowth, or both. BioGlue as a cause for such a complication has been reported only occasionally. We describe a case of a 63-year-old woman who underwent operation for symptomatic tight aortic stenosis. After implantation of an aortic valve (AGN-751, size 19; St. Jude Medical, St. Paul, MN, USA) because of a transverse tear of the aortic wall above the annulus occurring during the suturing of the aortotomy, a triangular Vascutek Dacron patch (Vascutek/Terumo, Inchinnan, Scotland, UK) was included. To secure hemostasis, BioGlue (CryoLife, Kennesaw, GA, USA) was applied. A transthoracic echocardiography (TTE) examination performed after signs of ischemia appeared in the electrocardiogram on postoperative day 5 revealed an aortic transvalvular gradient of 74/38 mm Hg and a functional valve area of 1.0 cm2. No coronary lesions were revealed in a coronarography evaluation, but cinefluoroscopy (CF) examination revealed immobility of 1 valve leaflet. The reoperation revealed a thick, rough layer of the glue on the inner side of the patch. This glue had run down to the valve, blocking a mechanical leaflet. Cleaning the valve was not possible, and the valve had to be changed. The subsequent postoperative course was uneventful. The transvalvular gradient was 39/20 mm Hg, and the functional valve area was 1.2 cm2. We believe that the use of BioGlue and other surgical sealants is justified to secure complex suture lines and for maintaining hemostasis in cardiac surgery, but some precautionary rules must be respected. Authors have indicated that the glue enters through the needle holes in such cases, but our findings suggest it can also pass to the Dacron patch itself. CF is superior to TTE and transesophageal echocardiography for analyzing movement of the mechanical valve leaflet, and cardiac catheterization is rarely needed.

BioGlue-Associated Loss of Aortic Valve Leaflet Motility Sonographically Masked by Both Newly Replaced Mechanical Aortic and Mitral Valves

“…There was one report where valvular dysfunction was not recognized until postoperative day 5, which then prompted return to the operating room for repair. 11 Our case is the first to report wherein both mitral and aortic valves were replaced and acted together to completely obliterate visualization of aortic valve leaflets across all TEE views.…”

“…Previous case reports of BioGlue-associated dysfunction of newly placed mechanical heart valves have been described. [5][6][7][8][9][10][11] Although presumed to be a rare event, it is difficult to know the actual incidence of such complications, as they are likely underreported. As with our case, most previous reports have described a situation wherein hemodynamic instability was encountered on attempted wean from CPB, which led to reinitiation of cardioplegia for subsequent repair.…”

“…It has been suggested that supplementation of TEE in similarly confusing situations with fluoroscopy might permit earlier detection and diagnostic certainty, although its role has not been critically elucidated. 10,11,13 Manufacturer instructions and indications for proper use of BioGlue are strict. 1 However, even with correct application, in vitro studies of BioGlue use to secure suture lines along fresh porcine aortic grafts and prosthetic grafts demonstrated BioGlue leakage through suture holes 10% of the time, independent of suture size.…”

“…It has been suggested that supplementation of TEE in similarly confusing situations with fluoroscopy might permit earlier detection and diagnostic certainty, although its role has not been critically elucidated. 10,11,13…”

Improved application technique of albumin-glutaraldehyde glue for repair of superficial lung defects

“…BioGlue™ is delivered in liquid form, which makes it prone to unintentional run-off. Reported consequences include among others a blocked leaflet after mechanical aortic valve replacement resulting in a high transvalvular gradient [ 10 ]. Our personal experience in lung surgery confirms that BioGlue™ run-off after sealing superficial lung defects is almost inevitable and leads to hardened strands often far away from the original lesion site.…”