Late wound healing problems after use of BioGlue for apical hemostasis during transapical aortic valve implantation

BioGlue (CryoLife Inc, Kenneswa, GA, USA), a bovine serum albumin-glutaraldehyde tissue sealant, was at times used to seal the myocardial holes of the polypropylene stitches at the apex of the heart during transapical aortic valve implantation (TAVI). We describe three patients who developed late wound healing problems after TAVI that were thought to be caused by BioGlue. The surgical wound revision was performed on the 115th, 41st and 60th days, respectively, after original TAVI procedures. At revision, a 'foreign body' reaction surrounded by healthy well-vascularized tissue was found. All intraoperative cultures were sterile despite evidence of purulent-like material at the time of wound debridement. The wounds healed 'per primam intentionem' and the patients' postoperative course was also completely uneventful.     

Delayed subtotal coronary obstruction after transapical aortic valve implantation

We report on an obstruction of the left main coronary artery which occurred after completion of an uneventful transapical aortic valve implantation (TAVI) procedure. This delayed subtotal coronary obstruction was detected by routine final transesophageal echocardiographic examination. Emergency implantation of a coronary stent eliminated myocardial ischemia. This case demonstrated that coronary artery obstruction can occur not only during the TAVI procedure but also some time later. This finding reinforces the idea that these patients must also be carefully evaluated in the early post-procedure period.     

Long-term mechanical circulatory support in 198 patients: largest single-center experience worldwide

During recent years, mechanical circulatory support (MCS) devices have been increasingly used for long-term support. Nevertheless, problems of embolic and bleeding complication, infections, and technical failure still inhibit successful permanent support. We analyzed the courses of 198 patients who were supported for >1 year by 12 different MCS devices. Of the 198 patients, 87 had first-generation MCS devices (pulsatile), 43 second-generation devices (nonpulsatile with standard bearings), and 68 third-generation devices (nonpulsatile with magnetic bearings), implanted between July 1994 and March 2009. The mean time on support of the total group was ～ 2 years (690 ± 321 [366-1,875] days). Of the first generation, 83 patients (95%) could be discharged; in the second and third group, all patients could be discharged. Rehospitalizations were observed in all patients. Reasons for readmission were coagulation disorders, wound infections, stroke, and technical failure. Seventy-seven patients received heart transplantation, 66 are still receiving support, 53 died, and two patients have been weaned from the device. All types of devices can be used for extended periods of time. Device- and nondevice-related rehospitalizations were observed in all three groups of patients. Close outpatient monitoring and support are crucial to ensure good long-term results.     

Conventional surgical repair and endovascular treatment of acute traumatic aortic rupture.

OBJECTIVE: Endoluminal aortic stent grafting offers a potentially less invasive alternative to open chest surgery, especially in patients with polytrauma. We compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture. METHODS: Retrospectively, 74 patients with acute traumatic aortic rupture were analyzed. Most of the patients had a rupture limited to the isthmus, and severe associated injuries. Thirty-five patients (6 female, 29 male, mean age 36 years) underwent surgical repair. Two patients were operated upon without cardiopulmonary bypass. In 39 patients (5 female, 34 male, mean age 36 years) thoracic endografts were implanted. The delay between trauma and treatment was comparable in the two groups. RESULTS: Hospital mortality was 20% (7 of 35 patients) in the surgical group and 7.7% (3 of 39 patients) in the endovascular group. The most common cause of death in the surgical group was brain death in severe traumatic patients. Ten surgical complications occurred in 5 patients: respiratory insufficiency (n=3), pulmonary infection (n=2), recurrent nerve palsy (n=2), repeat thoracotomy (n=2), and compartment syndrome (n=1). No patient in this group had paraplegia. Except for one case, which required conversion to conventional surgery, stent-graft implantation was successful in all cases, without peri-interventional complications or procedure-induced paraplegia. In 9 patients the left subclavian artery was covered with the device. Two patients underwent surgical repair 15 days and 4 months after endografting because of injury of the aortic wall by the stent and development of a spurious aneurysm, respectively. CONCLUSIONS: In the treatment of traumatic thoracic aortic rupture, the early outcome of patients treated with endovascular stent grafts appears to be better than that with conventional surgical repair. The new technique allows safe and successful repair of this life-threatening injury in the early phase of trauma management. How far this potential benefit is sustained in the long term remains unclear at present.