Blockage of a Mechanical Aortic Valve Leaflet with BioGlue: A Case Report
AbstractMechanical 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.
Barbetseas J, Zoghbi WA. 1998. Evaluation of prosthetic valve function and associated complications. Cardiol Clin 16:505-30.nBridgman JC, Chile W, Heddle W. 2006. Wolf in wolf's clothing—a case of prosthetic aortic valve thrombosis presenting as an acute coronary syndrome. Heart Lung Circ 15:334-6.nChhatriwalla AK, Lever HM, Pettersson G, Kapadia S. 2009. Role of invasive evaluation with cineradiography and intracardiac echocardiography to detect mechanical prosthetic valve dysfunction. J Invasive Cardiol 21:190-2.nGoldberg SP, Campbell DN. 2009. Mechanical aortic valve dysfunction due to biological glue. Ann Thorac Surg 88:671-2.nJelinek P, Vacha M, Sulda M. 2005. Images in cardiology: transoesophageal echocardiography showing a thrombosis of the aortic valve mechanical replacement before and after thrombolytic treatment. Heart 91:1351.nKarimi M, Kerber RE, Everett JE. 2005. Mechanical aortic valve malfunction: an intraoperative BioGlue complication. J Thorac Cardiovasc Surg 129:1442-3.nKaya EB, Kocabas U, Aytemir K, Tokgözoglu L. 2008. Successful fibrinolytic treatment in an old patient with acute aortic prosthetic thrombosis. Eur J Echocardiogr 9:581-3.nKhouzam RM. 2007. Cinefluoroscopy as the gold standard for mechanical valve mobility. Can J Cardiol 23:998.nKidher ES, Perera R, Rao C, Rehman SM, Sutaria N, Athanasiou T. 2009. A rare case of suture material obstructing the closure mechanism of a prosthetic aortic valve: a case report. Cases J 2:9126.nLeMaire SA, Carter SA, Won T, Wang X, Conklin LD, Coselli JS. 2005. The threat of adhesive embolization: BioGlue leaks through needle holes in aortic tissue and prosthetic grafts. Ann Thorac Surg 80:106-11.nMontorsi P, De Bernardi F, Muratori M, Cavoretto D, Pepi M. 2000. Role of cinefluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis. Am J Cardiol 85:58-64.nRusshard P, Weerasinghe A. 2011. Intermittent jamming of a bileaflet mechanical heart valve in the absence of an extrinsic cause of obstruction. Eur J Echocardiogr 12:E19.nShapira Y, Raanani E, Sagie A. 2006. "BioGlue" as a possible cause of acute blocked mechanical mitral valve leaflet. J Cardiovasc Surg (Torino) 47:581-3.nvon Mallek D, Heinz BC, Löffler BG, Mellert E 2008. Incidents of malfunction of mechanical heart valves as reported to the German Medical Devices Vigilance System [in German]. Dtsch Med Wochenschr 133:2008-13.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).