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Eur J Cardiothorac Surg 1999;15:564-570
© 1999 Elsevier Science NL
Division of Thoracic and Cardiovascular Surgery, Surgical center, Hannover Medical School, Carl-Neuberg-Strase 1, 30625 Hannover, Germany
Received 7 December 1998; received in revised form 8 February 1999; accepted 10 February 1999.
Corresponding author. Tel./fax: +49-511-5233447
e-mail: karck{at}thg.mh-hannover.de
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Abstract |
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 Top Abstract 1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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Key Words: Acute aortic dissection • Surgical treatment • Gelatin-resorcin-formalin glue
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1. Introduction |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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2. Patients and methods |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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The diagnosis of aortic dissection was made by echocardiography or computed tomography. All operations were performed within 14 days from the onset of symptoms. There were 128 patients with an acute aortic dissection type 1 whereas 20 presented with type 2 dissection according to DeBakey's classification. Ten patients (6.8%) had been diagnosed as having Marfan's syndrome. In two cases dissection was complicated by pregnancy. Seven patients had undergone previous cardiac surgery (coronary bypass grafting in one, aortic valve replacement in four, aortic valvuloplasty in one, and mitral valve replacement in one). In three further instances, previous aortic surgery (descending aortic replacement for chronic type B-aortic dissection in two patients, abdominal aortic replacement for abdominal aortic aneurysm in one patient) had been done. One patient had chronic type B aortic dissection with Marfan's syndrome. He developed a type A aortic dissection due to retrograde progression of the disease.
Preoperative clinical conditions varied significantly among the surgical candidates. Sixty-seven (45.3%) patients were admitted in cardiogenic shock. The vast majority of these (54/67 patients) presented signs of cardiac tamponade, three requiring cardiopulmonary resuscitation. Malperfusion of organs was observed in 30 (20.3%) patients with acute renal ischemia in six, bowel ischemia in two patients, critical leg ischemia in seven patients, spinal cord ischemia in two patients, signs of cerebrovascular ischemia in ten patients and signs of acute myocardial ischemia in addition to the symptoms of aortic dissection in three patients. Preoperative transthoracic or transesophageal echocardiography revealed mild to severe aortic regurgitation in 93 (62.8%) patients.
2.1. Operative techniques
The left or right femoral artery was cannulated prior to median sternotomy. Cardiopulmonary bypass (CPB) was established after subsequent cannulation of the right atrium. Core cooling was initiated. The ascending aorta was cross clamped at the origin of the innominate artery and incised longitudinally. Cardioplegic solution was administered directly into the coronary ostia. Based on the operative findings, the aortic root was treated as described below.
If the dissecting process reached below the sino-tubular junction and the aortic annulus and aortic valve were of normal size and configuration, the aortic root was reconstructed with GRF glue. The adhesive, including the activator was heated to 40°C. The glue was injected between the dissected layers, care being taken not to contaminate the left ventricular cavity, the aortic leaflets or tissue around the aortic root. The activator was then added to the glue using a cannula tipped syringe. Again, care was taken not to spill the fluid. Once the adhesive was injected, two different instruments were employed to compress the layers of the aortic wall. Whenever the outer surface of the aorta was accessible, the special clamps developed by Borst [5] were used. If the outer surface of the aorta was not easily accessible, a metal Hegar dilator of suitable size was inserted into the true lumen. After polymerization of the glue, the Dacron prosthesis was anastomosed to the reconstructed aortic root using a double armed continuous 3-0 or 4-0 polypropylene suture. We did not use any mattress type sutures or additional Teflon-felt reinforcement of the reconstructed aortic root.
In cases where the aortic annulus was dilated, the aortic valve was morphologically deformed, or severe aortic regurgitation was known before the onset of the dissection, the aortic valve and the dissected proximal layers were totally resected. Then, a composite graft bearing a mechanical bileaflet valve was inserted. If the dissection reached either coronary ostium without disrupting the coronary vessel, the dissected layers around the ostium were reconstructed with GRF glue.
The type of repair at the distal site depended on the location and the extension of the intimal tear. If the intimal tear was located in the ascending aorta only, this portion of the vessel alone was replaced. An open distal anastomosis including replacement of the proximal portion of the aortic arch was performed whenever the proximal segment of the aortic arch was dissected. Total aortic arch replacement was necessary in most of the cases where an entry tear was present in that portion of the vessel. The distal site of the dissected aorta was reconstructed with GRF glue in the same manner as described above for the proximal site. Here we also avoided mattress sutures and Teflon felt. In order to prevent spillage of the glue into the downstream aorta, suction was continuously applied between the dissected layers. Whenever surgery had to be extended into the aortic arch, deep hypothermia and circulatory arrest were used for cerebral protection.
According to the above strategy, 147 patients were treated by replacement of the ascending aorta with a woven Dacron graft. In all patients, GRF glue was used to reinforce the dissected layers of the proximal aorta, distal aorta or both. Thus, 105 proximal aortic reconstructions were performed including four repairs of dissected coronary ostia prior to reimplantation into a valved conduit and 144 distal aortic reconstructions. Ninety-three patients underwent additional aortic valve procedures: 54 patients had resuspension of one or more valve leaflets; three patients had a valve remodelling procedure and 36 patients underwent composite grafting. Among 148 patients with revision of the aortic arch in deep hypothermic circulatory arrest 111 patients received proximal and 37 total aortic arch replacement.
Mean cardiopulmonary bypass time was 139.9 min (range, 59–413 min) and mean aortic crossclamp time was 74.6 min (range, 29–157 min). The lowest nasopharyngeal temperature during circulatory arrest was 18.8°C (range, 13.0–28.0°C) and the average duration of circulatory arrest was 21.6 min (range, 3–65 min).
As concomitant procedures, coronary artery bypass grafting was performed in 12 patients, fenestration of the abdominal aorta in three, replacement of the infrarenal abdominal aorta in two as well as replacement of the descending aorta and nephrectomy of a transplanted kidney in 1 patient.
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3. Results |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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Among non-lethal postoperative complications there was developed postoperative hemorrhage requiring rethoracotomy in nine patients and postoperative myocardial infarction in two patients. New central neurological deficits were observed in 14 patients postoperatively, which completely resolved in six.
3.2. Late results
All of the 109 survivors were contacted (follow-up, 100%). There were 16 late postoperative deaths, with five patients dying early after reoperation. Another two patients each died due to rupture of the chronically dissected descending aorta and cerebrovascular vascular accident. The other causes of death were cardiac failure, respiratory failure, thrombosis of the superior mesenteric artery and metastatic lung cancer in one patient, each. Three other patients died due to unknown causes. Actuarial survival rates are 69.9% at 1 year after operation, 62.5% at 3 years, 59.4% at 5 years and 56.1% at 7 years after primary surgery (Fig. 1)
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In nine cases, intraoperative findings suggested that the pathology leading to reoperation was related to the previous use of GRF glue. None of these patients suffered from Marfan's syndrome. Seven patients had developed a redissection of the aortic root that had been previously reconstructed by use of GRF glue. In one, a dehiscence was found near the right coronary ostium after glue repair and another presented with a rupture near the distal anastomosis after downstream reconstruction with GRF glue. In all nine interventions, the glued segment of the vessel wall was found to be completely separated. Also, the redissected segment appeared macroscopically necrotic in five patients (Fig. 2) . However, subsequent histological examination which was performed in two cases revealed no necrosis but a ‘degenerative process’ in the medial layer. Relevant operative data of these nine patients are summarized in Table 1.
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4. Discussion |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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Patients with previous acute type A dissection may require reoperation for critical dilatation of the dissected downstream aorta. According to the recent report of Fann and colleagues [9] presenting a 30 years single center experience, the reoperation free rate for acute aortic dissection type A was 83, 65, and 65% at 5, 10, and 15 years after the initial operation without the use of any surgical adhesives. Another series including patients with GRF reconstruction of the dissected aorta was presented by Bachet and colleagues [12]. They reported a reoperation-free rate of 87.6, 80.9 and 66.4% at 5, 10 and 15 years after the initial operation. Despite all the well known limitations as to the comparability between such two-patient cohorts, these results suggest that the use of GRF glue had no impact on the incidence of reoperation.
In the series reported here, 20 patients were reoperated on, a total of 22 times. Among them, we identified nine patients with a dehiscence at a previously glued aortic segment near the vessel-to-graft junction. An aortic root redissection was found in seven out of nine patients intraoperatively, leading to preoperative symtpoms of subacute severe aortic valve regurgitation in six. Even though the intraoperative findings suggested necrosis formation in the glued segment, this was not proven by the subsequent histological evaluation, which was available in only two cases. Extensive fibrosis between the two layers of the aorta and the adjacent fibrous connective tissue with strechted elastic fibers as described previously was found instead [13,14].
Little experimental evidence is available for the potential toxic effects of the glue. In a rat model, Walker and colleagues did not observe any toxicity of the glue [15]. Ennker and co-workers [16] described the histological alterations that occured in pig aortas as a response to GRF glue. Unlike Walker, they observed a toxic effect of formalin, particularly in cases where an excessive amount of formalin was present, which therefore was not chemically bound to resorcin. Thus it is conceivable that our own observations are due to tissue necrosis resulting from too much of the formalin. On the other hand it is possible that redissections occured in dissected vessel segments, where an accidental inhomogenous mixture of the glue components prevented its proper action. According to Bachet, as few as two or three droplets of the polymerizing agent are enough to polymerize 1 ml of the gelatine resorcinol mixture. We therefore conclude, that no more than the minimal amount of the formalin component that enables sufficient polymerization should be administered to the gelatine resorcin mixture.
The clinical introduction of the GRF glue has undoubtedly facilitated reconstructive surgery in acute aortic dissection type A. However, it appears that a very precise mixture of the components is indispensible in order to prevent from its possible adverse effects on the tissue.
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Footnotes |
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Appendix. Appendix A. Conference discussion |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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Dr. Karck: No, we have not yet gone that far, but this data leaves us with a little bit of concern. I don't think that, we would go back to the Teflon felt reconstructions, because the other technique is much easier to do. However, we have to be aware that these things can obviously happen with the GRF glue. Maybe other less toxic substances will come up that will not show complications of this kind over the long term.
Dr. Antunes: I personally use the combination of three methods: (1) the use of the Teflon strips; (2) Impregnation of the layers with formalin or glutaraldehyde; (3) the use of fibrin glue rather than the resorcin glue. I don't know if that will make any difference.
Dr. A.G. Stolf (Sao Paulo, Brazil): We have, with type A dissection, around, 250 acute and 100 chronic type A dissesctions. In the majority of these cases we used the GRF glue. The only difference is that we modfied the polymerizing solution. Now, we do not use formaldehyde, it is a mixture of glutaraldehyde and formaldehyde. We went to the laboratory and investigated the histology with formaldehyde and the mixture of glutaraldehyde and formaldehyde in the aorta of dogs The inflammatory reaction was much less with the mixture. And so I think that the polymerizing solution is the important thing in inflammation and maybe in necrosis.We did not have any case of early and no case of late recurrence of aortic regurgitation or redissection that probably could be due to the GRF. But I agree with you that it is a matter of caution. There was no distal problem also that could be related to the GRF. So we go on using the glue. We go on using the strips, despite of the use of GRF. I think it is safer.
Dr. M. Turina (Zurich, Switzerland): We have the paper in the afternoon, presented by Dr. Niederhauser, which will give almost identical results and identical curves which can be superimposed. Our impression in Zurich with the use of the glue was similar. We had problems, but we thought that we could identify the amount glue being utilized as the primary culprit. These patients who had a so-called root reconstruction, just using the glue and no graft at all, had by far the worst results, and we reoperated on practically all of them. And our impression was that the extremely sparing use of the glue in the proximal segment is the clue to the success, or excessive use of glue is the reason for failure. What is your opinion?
Dr. Karck: Yes, I agree. Probably one has to be very careful not to overdose the amount of glue applied in between the dissected layers.
Dr. A. Haverich (Hannover, Germany): I just rise to confirm what Marko Turina just said. When we first identified the problem, we found that there was one surgeon heavily involved, and when doing the primary operation, he usually applied much more glue to the aortic root than the others. So I do think the amount of glue being used for that purpose does also influence the late results.
Dr. J. Bachet (Suresnes, France): I agree with you that in some cases necrosis can occur in the aortic tissues and that we have to be very cautious. But the necrosis is not due to the gelatin, of course, it is due to the formalin and the glutaraldehyde. And the only word of caution that comes to my mind is that too many colleagues use too much polymerizing agent when they use the glue. Only one or two drops are enough to polymerize the gelatin. So do not spread a lot of formalin around, because it will certainly result into necrosis.Your last slide reinforces this. If indeed necrosis was due to the GRF glue, how do you explain that it would necrose upstream and not downstream? The fact is that when we put the glue in the aortic root, we generally put too much formalin.
Dr. Karck: We considered this to be due to mechanical aspects related to the vicinity of the aortic valve.
Dr. S. Westaby (Oxford, UK): It was not clear to me the reasons for reoperation. You found necrosis at reoperation, but was the reason for reoperation aneurysm in the aortic root or aortic regugitation?
Dr. Karck: In most cases, it was aortic regurgitation, in a smaller number of cases, it was aortic root aneurysm formation that prompted us to propose the indication for reoperation.
Dr. Westaby: And just to say that I am very for this glue. We have had excellent results with it. It greatly simplifies aortic dissection surgery and reduces the mortality. And I would also say that I think you can repair virtually 90% of valves, unless they are bicuspid and abnormal before. You had a fairly high valve replacement rate in your series I felt.
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References |
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TopAbstract1. Introduction
2. Patients and methods...3. Results4. Discussion
Appendix. Appendix A. Conference...References |
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