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Aortic valve repair with fibrin glue for type a acute aortic dissection
Aortic Valve Repair With Fibrin Glue for Type A Acute Aortic Dissection Jacques R. Seguin, MD, PhD, Eric Picard, MD, Jean-Marc Frapier, MD, and Paul-Andre Chaptal, MD Thoracic and Cardiovascular Surgery Unit, CHU H6pital A. de Villeneuve, and the Laboratoire de Physiologie Cardio-Vasculaire, lnstitut de Biologie, Bd Henri IV, Montpellier, France
Repair of the acute aortic insufficiency associated with type A aortic dissection is now preferred to valve replacement. This is generally achieved by resuspending the aortic valve using different types of suturing techniques, with sutures usually passing through the aortic wall, which causes bleeding at the suture sites. We suggest, instead, simply injecting fibrin glue between the two dissected layers of the aortic annulus, which achieves resuspension of the aortic valve and reinforces the proximal stump without the need for any sutures. To evaluate the efficacy of this simple technique, the cases of 15 consecutive patients who underwent operative intervention for the treatment of the type A aortic dissection associated with acute aortic insufficiency between January 1989 and July 1993 were reviewed. The mean patient age was 63 ± 11.2 years (range, 43 to 74 years). All had massive 3+ or 4+ aortic insufficiency, documented preoperatively by transesophageal echocardiography. None had any history of aortic regurgitation. In all patients, the aortic repair was done in conjunction with a supracoro-
nary replacement of the ascending aorta with a collagenimpregnated graft attached using a running suture, after reinforcement of the dissected tissues with glue. There was one non-valve-related early death (6.7%) and no late mortality. At a mean follow-up of 2.3 years, all patients were in New York Heart Association functional class I and had a mean aortic insufficiency grade of 0.3 (range, 0 to 1 +). Follow-up computed tomography in all patients showed closure of the dissecting process on the proximal ascending aorta. These results suggest that the use of fibrin glue may represent a simple and effective technique for repairing the acute aortic insufficiency associated with aortic dissection. This technique facilitates performance of the operation, reduces the operative time, avoids the need for suturing during aortic valve repair which can make the aortic wall fragile, and reinforces dissected tissues before replacement of the ascending aorta.
T
uncontrollable bleeding arising after aortic unclamping. To prevent this complication and to facilitate the operative technique, we suggest resuspending the aortic commissures by simply gluing the two aortic layers of the aortic root with a fibrin sealant, without the use of any sutures. We report here the results of this technique.
he surgical treatment of type A acute aortic dissection has improved greatly in the past years, in great part due to the use of biologic [1] or synthetic [2-4] glue. Nevertheless, two aspects remain a subject of discussion: the adequate treatment of an intimal tear extending to the aortic arch and the correct management of an associated acute aortic regurgitation. The present report addresses the latter point. When type A aortic dissection is associated with acute aortic regurgitation in the presence of an apparently normal valve, many surgeons suggest performing valve repair rather than replacement [5-7], as implantation of a valve prosthesis not only predisposes to the possible development of thromboembolic, hemorrhagic, and valve degeneration complications, but false-lumen thrombosis may also be delayed by the effects of anticoagulant therapy. The valve is often repaired by resuspending the commissures with pledgeted sutures [5]. This technique may render the dissected aortic root fragile, with an important accompanying risk of major Presented at the Thirtieth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 31-Feb 2, 1994. Address reprint requests to Dr Seguin, Thoracic and Cardiovascular Surgery, CHU H6pital A. de Villeneuve, 34085 Montpellier Cx, France.
© 1994 by The Society of Thoracic Surgeons
(Ann Thorae Surg 1994;58:304-7)
Material and Methods From January 1989 to July 1993, 45 patients were operated on for the treatment of a Stanford type A acute aortic dissection. Fifteen patients (mean age, 63 ± 11.2 years; range, 43 to 74 years) had associated massive 3+ or 4+ aortic regurgitation documented preoperatively by transesophageal echocardiography. The 30 other patients had no serious aortic regurgitation. None had any history of aortic regurgitation. All had a history of hypertension and none had the stigmata of Marfan's disease or histopathologic evidence of aortitis or cystic medial necrosis. All patients were admitted to the surgical unit less than 24 hours after the first symptoms appeared, and were operated on within 24 hours. The operation was performed using hypothermic extracorporeal circulation (body temperature, 27° to 29°C) and moderate hemodilution (hematocrit, 25% to 30%). Cardio0003-4975/94/$7.00
Ann Thorae Surg 1994;58:304-7
plegia was induced with 500 mL of cold crystalloid Ringer's solution containing 15 mmol/L of potassium at 4°C infused into the left and right coronary artery ostia. Every 20 minutes, 250 mL of the same solution was injected. Topical cooling was achieved by continuous irrigation of the pericardium with iced saline at 4°C. A femoral artery was used for arterial inflow. After administration of cardioplegia, the aortic valve was inspected. If no previous lesion was evident, valve repair was initiated. First, the ascending aorta was totally resected. After this was completed, the false lumen was closed and fibrin sealant applied between the two dissected layers and over the proximal and distal aortic stumps to reinforce the dissected tissues at the suture sites. Glue was particularly applied around the dissected part of the aortic root and aortic annulus. No sutures were used to close the false lumen either proximally or distally. Once the glue hardened (approximately 10 minutes), a Dacron prosthesis was implanted using a 3-0 polypropylene running suture without double cuffing the two layers. At the proximal site, the suture was placed immediately above the coronary ostia, and, distally, immediately before the innominate artery. No sutures were used for resuspending the aortic valve. The glue is made of fibrin sealant components and comes in a kit (Immuno AG, Vienna, Austria) containing a human sealer protein concentrate 030 mg/mL); aprotinin, a fibrinolysis inhibitor (3,000 KIV /mL); dried bovine thrombin (500 IV/mL), and calcium chloride (40 mmol z L). The fibrin sealant was prepared as described by Redl and Schlag [8) and applied using a Duploject (Immuno AG) syringe. The solution takes 10 to 15 minutes to prepare and 10 minutes to dry after application.
Results There was one non-valve-related intraoperative death (6.7%) due to massive septicemia followed by fatal shock that occurred on the second postoperative day. All other patients did well. Immediate postoperative transthoracic echocardiography confirmed the absence of any residual aortic regurgitation. Follow-up computed tomography showed no residual dissection of the aortic root, but did show persistence of the dissection just beyond the glued zone on the aortic arch. The cases of all patients were reviewed and all underwent follow-up, bidimensional and color-flow Doppler transthoracic echocardiography, and thoracoabdominal computed tomography. The follow-up period ranged from 3 months to 4 years and 9 months (mean, 2.3 years). All patients were alive and in New York Heart Association functional class I at the time of their last follow-up. No aortic murmur was heard. A mean aortic insufficiency grade of 0.3 (range, 0 to 1 +) was noted at echocardiography. In all patients, follow-up computed tomography showed closure of the dissecting process on the proximal aortic stump, especially around the aortic annulus where the dissected layers had been glued.
SEGUIN ET AL AORTIC VALVE REPAIR AND ACUTE AORTIC DISSECTION
305
Comment Type A acute aortic dissection requires immediate surgical intervention to prevent intrapericardiaI rupture, correct aortic regurgitation, if present, and resect the intimal tear. To achieve these goals, the operation generally involves replacing the portion of aorta at risk, that is, replacing the ascending aorta with a Dacron prosthesis. When an acute aortic regurgitation is present, many authors have suggested doing repair rather than replacement [1, 6, 7]. The advantages of valve repair are numerous when compared to those of replacement, with or without reimplantation of the coronary arteries, and comprise reduced crossclamping time and perioperative bleeding, no valverelated complications (ie, thromboembolism and hemorrhage), no difficult reoperation for valve failure, and no anticoagulation, which would delay false-lumen thrombosis downstream from the repair. The mechanism of aortic regurgitation explains how the repair can be managed. Aortic regurgitation is due to severe dilation of the aortic annulus, and to dislocation and loss of commissural support [5-7], without any destruction of the valve itself. These lesions cause a loss of valvular coaptation in a previously normal valve. Restoration of valve competence can be achieved by resuspending the commissures and by the reattachment of the two dissected layers of the aortic annulus. It has been suggested that this can be achieved by continuous or interrupted mattress sutures buttressed with Teflon felts placed outside or inside the aortic wall, or both. However, the use of sutures on fragile dissected tissues may precipitate massive hemorrhage, resulting in perioperative or postoperative death or in postoperative complications. To prevent such complications, we suggest the application of glue to ensure the reattachment of the two dissected layers of the aortic annulus without the use of any sutures. When the glue has dried and reinforced the dissected proximal stump, then the proximal anastomosis to the aortic vascular prosthesis may be accomplished safely. This study showed that this technique accomplishes a satisfactory valve repair. In the immediate postoperative period, no residual aortic regurgitation was noted. At follow-up, up to 4 years and 9 months later, all patients were alive and well and had suffered no recurrent aortic regurgitation. The use of fibrin sealant also greatly simplifies the operation. It speeds up the operation: the technique we describe here takes approximately 20 to 30 minutes 00 to 20 minutes for glue application and 10 more minutes for it to dry), which is less than that required for an aortic valve replacement with coronary reimplantation, as performed by most surgeons. Furthermore, glue application may dominate the need for any sutures on the aortic root and it reinforces the proximal stump. Therefore, the risk of prolonged or repeated cardiopulmonary bypass for surgical hemostasis is decreased. With such advantages, aortic valve repair using fibrin glue, as we describe it here, may confer improved surgical results, thereby reducing the intraoperative mortality and smoothing the postoperative course.
306
Ann Thorac Surg
SEGUIN ET AL AORTIC VALVE REPAIR AND ACUTE AORTIC DISSECTION
The use of glue for the repair of aortic dissections has been previously suggested, initially by Guilmet and associates [2] and confirmed by Bachet and colleagues [3, 4]. The glue used by these authors was made of gelatin, resorcinol, and formaldehyde. Rather than the formaldehyde, which may destroy the underlying tissues, we prefer a glue made of a biologic human sealer protein concentrate [1,9]. Better preservation of the glued portion of the aorta and the aortic annulus may be expected from such a fibrin sealant. Furthermore, biologic glue may be spread over the adventitia of the dissected aorta, provides additional reinforcement to the underlying tissue, and reduces the risk of bleeding through the suture holes. This is not possible with a gelatin-resorcinol-formaldehyde glue. Finally, the long-term efficacy of this technique is a concern, and the adhesive status of the two layers should be examined. The follow-up findings (up to 4 years and 9 months) in our patients were very encouraging. To date, all patients are well and have not suffered redissection or aneurysm, neither seen clinically nor on the follow-up computed tomographic scan. However, a more extensive follow-up of these patients is necessary before any definite conclusions concerning long-term results can be drawn. These results suggest that the use of biologic glue without any sutures may represent a simple and effective technique to repair acute aortic insufficiency associated with aortic dissection. This technique facilitates the surgical procedure, reduces the operative time, avoids suturing and the weakening of the aortic wall during aortic valve
1994;58:304-7
repair, and reinforces dissected tissues before replacement of the ascending aorta.
References 1. Seguin JR, Frapier J-M, Colson P, Chaptal P A. Fibrin sealant improves surgical results of type A acute aortic dissections. Ann Thorac Surg 1991;52:745-9. 2. Guilmet D, Bacher J, Goudot B, et a1. Use of biological glue in acute aortic dissection: preliminary clinical results with a new surgical technique. J Thorac Cardiovasc Surg 1979;77:516-21. 3. Bachet J, Gigou F, Laurian C, Bical 0, Goudot B, Guilmet D. Four-year clinical experience with the gelatin-resorcine-formol biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 1982;83:212-7. 4. Bachet J, Teodori G, Goudot B, et a1. Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. J Thorac Cardiovasc Surg 1988;96: 878-86. 5. Cachera JP, Vouhe PR, Loisance DY, et a1. Surgical management of acute dissections involving the ascending aorta. Early and late results in 38 patients. J Thorac Cardiovasc Surg 1981;82:576-84. 6. Fann [I, Glower DD, Miller DC, et a1. Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation. J Thorac Cardiovasc Surg 1991;102:62-75. 7. Mazzucotelli j-P, Deleuze PH, Baufreton C, et a1. Preservation of the aortic valve in acute aortic dissection: long-term echocardiographic assessment and clinical outcome. Ann Thorac Surg 1993;55:1513-7. 8. Redl H, Schlag G. Fibrin sealants and its modes of application. In: Redl H, Schlag G, eds. Thoracic surgery-cardiovascular surgery. Fibrin sealant in operative medicine, Vol 5. Berlin, Heidelberg: Springer-Verlag, 1986:13-26. 9. Seguin JR, Frapier J-M, Colson P, Chaptal P A. Fibrin sealant for early repair of acquired ventricular septal defects. J Thorac Cardiovasc Surg 1992;104:748-51.
DISCUSSION DR ALEXANDER S. GEHA (Cleveland, OH): I congratulate Dr Seguin and his associates for this nicely presented paper. I have a question for you, and perhaps a comment at the same time. We have used the gelatin-resorcinol-formaldehyde (GRF) glue for this purpose, and have done the repairs exactly the same way as you described for fibrin glue without using buttress sutures once we have used the GRF glue. It does indeed give you a very nice area to sew to and a very nice wall that suspends the aortic valve, and gets rid of the aortic valve incompetence. I also agree with you that, theoretically, the biologic glue is attractive. My question is, have you used the GRF glue and, if so, what has your experience with it been, and, furthermore, have you seen any negative or really detracting results from the use of GRF glue? DR SEGUIN: Recently we have also been using the GRF glue, and we have not, on a short-term follow-up, encountered any problem. Other teams have reported on their experience with the GRF glue during a very long follow-up, and their results have been excellent. DR RONALD C. ELKINS (Oklahoma City, OK): We have heard in the last day and a half the importance of obliterating the distal lumen in the patient who has suffered dissection, as it affects the long-term survival of those patients. Do you have information about the incidence of a patent distal lumen in your patient
population who have had their dissection of the false lumen closed with glue? DR SEGUIN: Our attitude concerning the distal stump is the following: When the intimal tear extends onto the aortic arch, rather than changing the aortic arch, we then, under circulatory arrest, glue this part of the arch instead of replacing it. It was very interesting for us to follow up these patients. When we have achieved correct gluing of this part of the aorta, we have noted very satisfactory results for the part that was glued, during a follow-up of as much as 5 years. But, we cannot glue as far as we would like to, that is, for instance, on the descending thoracic aorta, which stays dissected. DR ELKINS: You cannot see an advantage to glue in terms of its effect on the patency of the distal lumen? DR SEGUIN: Apparently not. DR DENTON A. COOLEY (Houston, TX): I may have missed this in the presentation. First, did you use hypothermic circulatory arrest for the distal repair? The cold conditions sometimes interfere, in my experience, with using the resorcinol glue, which works best when it is warm. Have you an opinion about the relative adhesiveness of fibrin
Ann Thorac Surg 1994;58:304-7
glue as opposed to the resorcinol glue? Would it be possible using fibrin glue to simply inject the fibrin glue into the false passage without excision of the aorta? DR SEGUIN: Thank you very much for these numerous questions. I will try to answer all of them. First, concerning circulatory arrest, we use this technique when, as I just said, the intimal tear is either not found on the ascending aorta or extends to the aortic arch. Otherwise, when we find the intimal tear on the ascending aorta we just replace the ascending aorta and we do not induce any circulatory arrest. Concerning the temperature of the fibrin glue, it is not necessary to heat it up, as we need to with the GRF glue. It can be used at the normal temperature of the operating room. The last question you asked, if I am right, is whether we tried to use only fibrin glue without replacing the ascending aorta. No, we did not. DR COOLEY: Do you have any idea about the relative adhesiveness of the two products, either the fibrin or the resorcinol glue? DR SEGUIN: Absolutely. The adhesiveness is quite comparable, in our view, when either glue is used between the two dissected layers. However, we found many advantages to the fibrin glue on the external part of the aorta, an advantage we did not observe for the GRF glue. DR GILLES D. DREYFUS (Suresnes, France): I would like to congratulate Dr Seguin and associates on this paper. Although I
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belong to the group at Foch Hospital that has introduced GRF biologic glue for use in the repair of aortic dissection, and have presented four papers at the American Association of Thoracic Surgery concerning our results with this glue in this setting, I personally believe that GRF glue has not got the same adhesive properties as fibrin glue. Some surgeons have already used fibrin glue for the repair of aortic dissection and have not found the same results in the long term. Concerning the use of gluing as the only treatment, it has already been done in 50 patients, in another hospital in Paris, and there has been a high rate of recurrence of dissection. Therefore, in my opinion, it should not be recommended as an adequate treatment. I would like to know what has induced Dr Seguin to switch from a well-known biologic glue to fibrin glue, which is more a hemostatic glue than a sealant glue. DR SEGUIN: Thank you for these comments. We did not switch from GRF to fibrin glue. We rather recently went the other way, in an attempt to compare the two glues. We started using fibrin glue in 1985 with very satisfactory results in simple cases, subsequently extending its use to aortic valve repair or to gluing the aortic arch. We have a very positive feeling about not only the glue when it is between the two layers, but also when we put glue on the external part of the aorta. We found that fibrin glue achieves much better adhesion and gives us a much better feeling. That is why we chose this glue when we started with our experience. Now we are trying to compare the two glues, and, so far, no apparent major differences have been observed.
Repair of the acute aortic insufficiency associated with type A aortic dissection is now preferred to valve replacement. This is generally achieved by resuspending the aortic valve using different types of suturing techniques, with sutures usually passing through the aortic wall, which causes bleeding at the suture sites. We suggest, instead, simply injecting fibrin glue between the two dissected layers of the aortic annulus, which achieves resuspension of the aortic valve and reinforces the proximal stump without the need for any sutures. To evaluate the efficacy of this simple technique, the cases of 15 consecutive patients who underwent operative intervention for the treatment of the type A aortic dissection associated with acute aortic insufficiency between January 1989 and July 1993 were reviewed. The mean patient age was 63 ± 11.2 years (range, 43 to 74 years). All had massive 3+ or 4+ aortic insufficiency, documented preoperatively by transesophageal echocardiography. None had any history of aortic regurgitation. In all patients, the aortic repair was done in conjunction with a supracoro-
nary replacement of the ascending aorta with a collagenimpregnated graft attached using a running suture, after reinforcement of the dissected tissues with glue. There was one non-valve-related early death (6.7%) and no late mortality. At a mean follow-up of 2.3 years, all patients were in New York Heart Association functional class I and had a mean aortic insufficiency grade of 0.3 (range, 0 to 1 +). Follow-up computed tomography in all patients showed closure of the dissecting process on the proximal ascending aorta. These results suggest that the use of fibrin glue may represent a simple and effective technique for repairing the acute aortic insufficiency associated with aortic dissection. This technique facilitates performance of the operation, reduces the operative time, avoids the need for suturing during aortic valve repair which can make the aortic wall fragile, and reinforces dissected tissues before replacement of the ascending aorta.
T
uncontrollable bleeding arising after aortic unclamping. To prevent this complication and to facilitate the operative technique, we suggest resuspending the aortic commissures by simply gluing the two aortic layers of the aortic root with a fibrin sealant, without the use of any sutures. We report here the results of this technique.
he surgical treatment of type A acute aortic dissection has improved greatly in the past years, in great part due to the use of biologic [1] or synthetic [2-4] glue. Nevertheless, two aspects remain a subject of discussion: the adequate treatment of an intimal tear extending to the aortic arch and the correct management of an associated acute aortic regurgitation. The present report addresses the latter point. When type A aortic dissection is associated with acute aortic regurgitation in the presence of an apparently normal valve, many surgeons suggest performing valve repair rather than replacement [5-7], as implantation of a valve prosthesis not only predisposes to the possible development of thromboembolic, hemorrhagic, and valve degeneration complications, but false-lumen thrombosis may also be delayed by the effects of anticoagulant therapy. The valve is often repaired by resuspending the commissures with pledgeted sutures [5]. This technique may render the dissected aortic root fragile, with an important accompanying risk of major Presented at the Thirtieth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 31-Feb 2, 1994. Address reprint requests to Dr Seguin, Thoracic and Cardiovascular Surgery, CHU H6pital A. de Villeneuve, 34085 Montpellier Cx, France.
© 1994 by The Society of Thoracic Surgeons
(Ann Thorae Surg 1994;58:304-7)
Material and Methods From January 1989 to July 1993, 45 patients were operated on for the treatment of a Stanford type A acute aortic dissection. Fifteen patients (mean age, 63 ± 11.2 years; range, 43 to 74 years) had associated massive 3+ or 4+ aortic regurgitation documented preoperatively by transesophageal echocardiography. The 30 other patients had no serious aortic regurgitation. None had any history of aortic regurgitation. All had a history of hypertension and none had the stigmata of Marfan's disease or histopathologic evidence of aortitis or cystic medial necrosis. All patients were admitted to the surgical unit less than 24 hours after the first symptoms appeared, and were operated on within 24 hours. The operation was performed using hypothermic extracorporeal circulation (body temperature, 27° to 29°C) and moderate hemodilution (hematocrit, 25% to 30%). Cardio0003-4975/94/$7.00
Ann Thorae Surg 1994;58:304-7
plegia was induced with 500 mL of cold crystalloid Ringer's solution containing 15 mmol/L of potassium at 4°C infused into the left and right coronary artery ostia. Every 20 minutes, 250 mL of the same solution was injected. Topical cooling was achieved by continuous irrigation of the pericardium with iced saline at 4°C. A femoral artery was used for arterial inflow. After administration of cardioplegia, the aortic valve was inspected. If no previous lesion was evident, valve repair was initiated. First, the ascending aorta was totally resected. After this was completed, the false lumen was closed and fibrin sealant applied between the two dissected layers and over the proximal and distal aortic stumps to reinforce the dissected tissues at the suture sites. Glue was particularly applied around the dissected part of the aortic root and aortic annulus. No sutures were used to close the false lumen either proximally or distally. Once the glue hardened (approximately 10 minutes), a Dacron prosthesis was implanted using a 3-0 polypropylene running suture without double cuffing the two layers. At the proximal site, the suture was placed immediately above the coronary ostia, and, distally, immediately before the innominate artery. No sutures were used for resuspending the aortic valve. The glue is made of fibrin sealant components and comes in a kit (Immuno AG, Vienna, Austria) containing a human sealer protein concentrate 030 mg/mL); aprotinin, a fibrinolysis inhibitor (3,000 KIV /mL); dried bovine thrombin (500 IV/mL), and calcium chloride (40 mmol z L). The fibrin sealant was prepared as described by Redl and Schlag [8) and applied using a Duploject (Immuno AG) syringe. The solution takes 10 to 15 minutes to prepare and 10 minutes to dry after application.
Results There was one non-valve-related intraoperative death (6.7%) due to massive septicemia followed by fatal shock that occurred on the second postoperative day. All other patients did well. Immediate postoperative transthoracic echocardiography confirmed the absence of any residual aortic regurgitation. Follow-up computed tomography showed no residual dissection of the aortic root, but did show persistence of the dissection just beyond the glued zone on the aortic arch. The cases of all patients were reviewed and all underwent follow-up, bidimensional and color-flow Doppler transthoracic echocardiography, and thoracoabdominal computed tomography. The follow-up period ranged from 3 months to 4 years and 9 months (mean, 2.3 years). All patients were alive and in New York Heart Association functional class I at the time of their last follow-up. No aortic murmur was heard. A mean aortic insufficiency grade of 0.3 (range, 0 to 1 +) was noted at echocardiography. In all patients, follow-up computed tomography showed closure of the dissecting process on the proximal aortic stump, especially around the aortic annulus where the dissected layers had been glued.
SEGUIN ET AL AORTIC VALVE REPAIR AND ACUTE AORTIC DISSECTION
305
Comment Type A acute aortic dissection requires immediate surgical intervention to prevent intrapericardiaI rupture, correct aortic regurgitation, if present, and resect the intimal tear. To achieve these goals, the operation generally involves replacing the portion of aorta at risk, that is, replacing the ascending aorta with a Dacron prosthesis. When an acute aortic regurgitation is present, many authors have suggested doing repair rather than replacement [1, 6, 7]. The advantages of valve repair are numerous when compared to those of replacement, with or without reimplantation of the coronary arteries, and comprise reduced crossclamping time and perioperative bleeding, no valverelated complications (ie, thromboembolism and hemorrhage), no difficult reoperation for valve failure, and no anticoagulation, which would delay false-lumen thrombosis downstream from the repair. The mechanism of aortic regurgitation explains how the repair can be managed. Aortic regurgitation is due to severe dilation of the aortic annulus, and to dislocation and loss of commissural support [5-7], without any destruction of the valve itself. These lesions cause a loss of valvular coaptation in a previously normal valve. Restoration of valve competence can be achieved by resuspending the commissures and by the reattachment of the two dissected layers of the aortic annulus. It has been suggested that this can be achieved by continuous or interrupted mattress sutures buttressed with Teflon felts placed outside or inside the aortic wall, or both. However, the use of sutures on fragile dissected tissues may precipitate massive hemorrhage, resulting in perioperative or postoperative death or in postoperative complications. To prevent such complications, we suggest the application of glue to ensure the reattachment of the two dissected layers of the aortic annulus without the use of any sutures. When the glue has dried and reinforced the dissected proximal stump, then the proximal anastomosis to the aortic vascular prosthesis may be accomplished safely. This study showed that this technique accomplishes a satisfactory valve repair. In the immediate postoperative period, no residual aortic regurgitation was noted. At follow-up, up to 4 years and 9 months later, all patients were alive and well and had suffered no recurrent aortic regurgitation. The use of fibrin sealant also greatly simplifies the operation. It speeds up the operation: the technique we describe here takes approximately 20 to 30 minutes 00 to 20 minutes for glue application and 10 more minutes for it to dry), which is less than that required for an aortic valve replacement with coronary reimplantation, as performed by most surgeons. Furthermore, glue application may dominate the need for any sutures on the aortic root and it reinforces the proximal stump. Therefore, the risk of prolonged or repeated cardiopulmonary bypass for surgical hemostasis is decreased. With such advantages, aortic valve repair using fibrin glue, as we describe it here, may confer improved surgical results, thereby reducing the intraoperative mortality and smoothing the postoperative course.
306
Ann Thorac Surg
SEGUIN ET AL AORTIC VALVE REPAIR AND ACUTE AORTIC DISSECTION
The use of glue for the repair of aortic dissections has been previously suggested, initially by Guilmet and associates [2] and confirmed by Bachet and colleagues [3, 4]. The glue used by these authors was made of gelatin, resorcinol, and formaldehyde. Rather than the formaldehyde, which may destroy the underlying tissues, we prefer a glue made of a biologic human sealer protein concentrate [1,9]. Better preservation of the glued portion of the aorta and the aortic annulus may be expected from such a fibrin sealant. Furthermore, biologic glue may be spread over the adventitia of the dissected aorta, provides additional reinforcement to the underlying tissue, and reduces the risk of bleeding through the suture holes. This is not possible with a gelatin-resorcinol-formaldehyde glue. Finally, the long-term efficacy of this technique is a concern, and the adhesive status of the two layers should be examined. The follow-up findings (up to 4 years and 9 months) in our patients were very encouraging. To date, all patients are well and have not suffered redissection or aneurysm, neither seen clinically nor on the follow-up computed tomographic scan. However, a more extensive follow-up of these patients is necessary before any definite conclusions concerning long-term results can be drawn. These results suggest that the use of biologic glue without any sutures may represent a simple and effective technique to repair acute aortic insufficiency associated with aortic dissection. This technique facilitates the surgical procedure, reduces the operative time, avoids suturing and the weakening of the aortic wall during aortic valve
1994;58:304-7
repair, and reinforces dissected tissues before replacement of the ascending aorta.
References 1. Seguin JR, Frapier J-M, Colson P, Chaptal P A. Fibrin sealant improves surgical results of type A acute aortic dissections. Ann Thorac Surg 1991;52:745-9. 2. Guilmet D, Bacher J, Goudot B, et a1. Use of biological glue in acute aortic dissection: preliminary clinical results with a new surgical technique. J Thorac Cardiovasc Surg 1979;77:516-21. 3. Bachet J, Gigou F, Laurian C, Bical 0, Goudot B, Guilmet D. Four-year clinical experience with the gelatin-resorcine-formol biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 1982;83:212-7. 4. Bachet J, Teodori G, Goudot B, et a1. Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. J Thorac Cardiovasc Surg 1988;96: 878-86. 5. Cachera JP, Vouhe PR, Loisance DY, et a1. Surgical management of acute dissections involving the ascending aorta. Early and late results in 38 patients. J Thorac Cardiovasc Surg 1981;82:576-84. 6. Fann [I, Glower DD, Miller DC, et a1. Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation. J Thorac Cardiovasc Surg 1991;102:62-75. 7. Mazzucotelli j-P, Deleuze PH, Baufreton C, et a1. Preservation of the aortic valve in acute aortic dissection: long-term echocardiographic assessment and clinical outcome. Ann Thorac Surg 1993;55:1513-7. 8. Redl H, Schlag G. Fibrin sealants and its modes of application. In: Redl H, Schlag G, eds. Thoracic surgery-cardiovascular surgery. Fibrin sealant in operative medicine, Vol 5. Berlin, Heidelberg: Springer-Verlag, 1986:13-26. 9. Seguin JR, Frapier J-M, Colson P, Chaptal P A. Fibrin sealant for early repair of acquired ventricular septal defects. J Thorac Cardiovasc Surg 1992;104:748-51.
DISCUSSION DR ALEXANDER S. GEHA (Cleveland, OH): I congratulate Dr Seguin and his associates for this nicely presented paper. I have a question for you, and perhaps a comment at the same time. We have used the gelatin-resorcinol-formaldehyde (GRF) glue for this purpose, and have done the repairs exactly the same way as you described for fibrin glue without using buttress sutures once we have used the GRF glue. It does indeed give you a very nice area to sew to and a very nice wall that suspends the aortic valve, and gets rid of the aortic valve incompetence. I also agree with you that, theoretically, the biologic glue is attractive. My question is, have you used the GRF glue and, if so, what has your experience with it been, and, furthermore, have you seen any negative or really detracting results from the use of GRF glue? DR SEGUIN: Recently we have also been using the GRF glue, and we have not, on a short-term follow-up, encountered any problem. Other teams have reported on their experience with the GRF glue during a very long follow-up, and their results have been excellent. DR RONALD C. ELKINS (Oklahoma City, OK): We have heard in the last day and a half the importance of obliterating the distal lumen in the patient who has suffered dissection, as it affects the long-term survival of those patients. Do you have information about the incidence of a patent distal lumen in your patient
population who have had their dissection of the false lumen closed with glue? DR SEGUIN: Our attitude concerning the distal stump is the following: When the intimal tear extends onto the aortic arch, rather than changing the aortic arch, we then, under circulatory arrest, glue this part of the arch instead of replacing it. It was very interesting for us to follow up these patients. When we have achieved correct gluing of this part of the aorta, we have noted very satisfactory results for the part that was glued, during a follow-up of as much as 5 years. But, we cannot glue as far as we would like to, that is, for instance, on the descending thoracic aorta, which stays dissected. DR ELKINS: You cannot see an advantage to glue in terms of its effect on the patency of the distal lumen? DR SEGUIN: Apparently not. DR DENTON A. COOLEY (Houston, TX): I may have missed this in the presentation. First, did you use hypothermic circulatory arrest for the distal repair? The cold conditions sometimes interfere, in my experience, with using the resorcinol glue, which works best when it is warm. Have you an opinion about the relative adhesiveness of fibrin
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glue as opposed to the resorcinol glue? Would it be possible using fibrin glue to simply inject the fibrin glue into the false passage without excision of the aorta? DR SEGUIN: Thank you very much for these numerous questions. I will try to answer all of them. First, concerning circulatory arrest, we use this technique when, as I just said, the intimal tear is either not found on the ascending aorta or extends to the aortic arch. Otherwise, when we find the intimal tear on the ascending aorta we just replace the ascending aorta and we do not induce any circulatory arrest. Concerning the temperature of the fibrin glue, it is not necessary to heat it up, as we need to with the GRF glue. It can be used at the normal temperature of the operating room. The last question you asked, if I am right, is whether we tried to use only fibrin glue without replacing the ascending aorta. No, we did not. DR COOLEY: Do you have any idea about the relative adhesiveness of the two products, either the fibrin or the resorcinol glue? DR SEGUIN: Absolutely. The adhesiveness is quite comparable, in our view, when either glue is used between the two dissected layers. However, we found many advantages to the fibrin glue on the external part of the aorta, an advantage we did not observe for the GRF glue. DR GILLES D. DREYFUS (Suresnes, France): I would like to congratulate Dr Seguin and associates on this paper. Although I
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belong to the group at Foch Hospital that has introduced GRF biologic glue for use in the repair of aortic dissection, and have presented four papers at the American Association of Thoracic Surgery concerning our results with this glue in this setting, I personally believe that GRF glue has not got the same adhesive properties as fibrin glue. Some surgeons have already used fibrin glue for the repair of aortic dissection and have not found the same results in the long term. Concerning the use of gluing as the only treatment, it has already been done in 50 patients, in another hospital in Paris, and there has been a high rate of recurrence of dissection. Therefore, in my opinion, it should not be recommended as an adequate treatment. I would like to know what has induced Dr Seguin to switch from a well-known biologic glue to fibrin glue, which is more a hemostatic glue than a sealant glue. DR SEGUIN: Thank you for these comments. We did not switch from GRF to fibrin glue. We rather recently went the other way, in an attempt to compare the two glues. We started using fibrin glue in 1985 with very satisfactory results in simple cases, subsequently extending its use to aortic valve repair or to gluing the aortic arch. We have a very positive feeling about not only the glue when it is between the two layers, but also when we put glue on the external part of the aorta. We found that fibrin glue achieves much better adhesion and gives us a much better feeling. That is why we chose this glue when we started with our experience. Now we are trying to compare the two glues, and, so far, no apparent major differences have been observed.