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Floating fibrin mass in the left ventricle after fibrin glue use in left ventricular reconstruction: A case report

Open AccessPublished:September 26, 2022DOI:https://doi.org/10.1016/j.xjtc.2022.09.011
      Figure thumbnail fx1
      The removed fibrin mass from the left ventricular cavity.
      Use of fibrin glue in left ventriculoplasty can be dangerous. The recommendations for fibrin glue and intraoperative TEE are vital. The prophylactic use of fibrin glue should be reconsidered.
      FG is widely used in cardiac surgery and considered to be safe. Herein, we report a case in which FG used to attain hemostasis of the suture line in left ventriculoplasty leaked into the left ventricular cavity as a floating mass.

      Case Presentation

      A 66-year-old man was brought to our department because of a pseudoaneurysm in the posterior wall of the left ventricle (Figure 1). He had undergone an extended sandwich patch procedure 3 years previously for a postmyocardial infarction ventricular septal perforation due to an occlusion of the right coronary artery. Although there were no symptoms, he underwent urgent surgery due to the risk of rupture.
      Figure thumbnail gr1
      Figure 1A preoperative contrast enhanced computed tomography image. A pseudoaneurysm was found in the in the posterior wall of the left ventricle.
      The patient underwent a median sternotomy. Cardiopulmonary bypass was established via the ascending aorta and right atrium. The aorta was clamped, and antegrade cold blood cardioplegia was administered intermittently. When the pseudoaneurysm was incised, a large thrombus was found. The patch on the left ventricular side, which was the orifice of the pseudoaneurysm, was semicircumferentially detached. The orifice was located near the posterior papillary muscle and was subsequently closed using a Dacron patch with double sutures. Beriplast P (CSL Behring K.K.) was applied to suture line with fibrinogen solution and thrombin solution in that order, then BioGlue (CryoLife Inc) was applied. The outer wall of the pseudoaneurysm was closed, the aorta was declamped, and the heartbeat resumed spontaneously.
      Transesophageal echocardiography (TEE) revealed a floating structure around the aortic valve. It was thought that the mitral chorda tendinea were partially ruptured. However, after the second cardioplegic arrest, an incision was made on the right side of the left atrium and a 3- × 20-mm fibrin mass (FM) was found in the left ventricle. The mass was removed, then the aorta was declamped. However, the TEE revealed a structure attached to the back of the anterior leaflet of the mitral valve. After the third cardioplegic arrest, the left ventricular cavity was observed through the aortic valve and a 5- × 10- mm FM was found attached to the papillary muscle of the anterior leaflet of the mitral valve. The mass was removed. During the surgery, heparin was administered to keep the activated clotting time over 400 seconds, and protamine was administered after the second FM removal. Images of the removed masses are shown in Figure 2. The TEE revealed no abnormal structures; therefore, surgery was completed (Video 1). The postoperative course was uneventful, and the patient was discharged unaided on postoperative day 16.
      Figure thumbnail gr2
      Figure 2The fibrin mass removed from the left ventricular cavity. Fibrin glue used for hemostasis of the suture line after the left ventriculoplasty. The fibrin glue leaked into the left ventricular cavity as a floating mass.

      Discussion

      Fibrin glue (FG) is widely used for hemostasis, and its usefulness has been reported. However, the routine use of FG and the necessary precautions to ensure safety need further examination. A systematic review and meta-analysis by Daud and Kaur
      • Daud A.
      • Kaur B.
      Fibrin and thrombin sealants in vascular and cardiac surgery: a systematic review and meta-analysis.
      showed that the use of FG significantly reduced the blood loss and operative time. However, no significant differences in the postoperative blood transfusion volume, reoperation rate, or 30-day mortality were observed. Thus, the study suggested that FG should be used selectively rather than routinely in cardiovascular surgery. The use of FG in coronary artery bypass grafting can reportedly increase the 30-day mortality.
      • Goerler H.
      • Oppelt P.
      Safety of the use of Tissucol Duo S in cardiovascular surgery: retrospective analysis of 2149 patients after coronary artery bypass grafting.
      On the basis of these reports, the routine use of FG is not recommended.
      We experienced the FG applied to the outside of the heart, infiltrating the inside of the heart. A similar report described that the FG applied at the anastomosis of a synthetic vessel graft leaked into the aorta and adhered to the aortic valve, emphasizing the importance of a comprehensive TEE study before weaning from cardiopulmonary bypass.
      • Nakahira J.
      • Ishii H.
      Fibrin glue on an aortic cusp detected by transesophageal echocardiography after valve-sparing aortic valve replacement: a case report.
      To avoid serious complications when FG is used, we should evaluate for foreign bodies and other abnormalities.
      In this case, the FG was applied without reducing the suction pressure of the left ventricular vent. This negative suction pressure might have caused FG leakage into the cardiac cavity. In addition, the amount of glue applied may have been too much; therefore, it may be better to apply a small amount and add more if insufficient. Having the anastomosed structure filled with blood may be effective too. Minato and Shimokawa
      • Minato A.
      • Shimokawa T.
      New application method of fibrin glue for more effective hemostasis in cardiovascular surgery: rub and spray method.
      also studied the use of FG for needle holes and found that the rub-and-spray method, ie, rubbing solution A (containing fibrinogen) on the needle holes, followed by spraying both A and B solutions (containing thrombin and calcium chloride) using an application nozzle, had the best hemostatic effect. The thrombus formation could be prevented by a specific polymerization reaction of the fibrin by spraying solutions A and B.
      • Minato A.
      • Shimokawa T.
      New application method of fibrin glue for more effective hemostasis in cardiovascular surgery: rub and spray method.
      Despite these improvements, one should be aware of the potential risk of embolic complications caused by FG, and the prophylactic application of FG in left ventriculoplasty should be evaluated further. Informed consent was obtained orally to submit and publish this report.

      Supplementary Data

      References

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        Fibrin and thrombin sealants in vascular and cardiac surgery: a systematic review and meta-analysis.
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        Safety of the use of Tissucol Duo S in cardiovascular surgery: retrospective analysis of 2149 patients after coronary artery bypass grafting.
        Eur J Cardiothorac Surg. 2007; 32: 560-566
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        Fibrin glue on an aortic cusp detected by transesophageal echocardiography after valve-sparing aortic valve replacement: a case report.
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        New application method of fibrin glue for more effective hemostasis in cardiovascular surgery: rub and spray method.
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