Transesophageal Echocardiographic Detection Of Intracardiac Bioglue (R) Postmitral Valve Replacement

A 74-yr-old woman with symptomatic severe mitral stenosis presented for mitral valve replacement surgery. Her comorbidities included diabetes mellitus, chronic obstructive pulmonary disease, and chronic atrial fibrillation. Intraoperatively, the posterior mitral annulus was found to be extensively calcified and required surgical decalcification followed by a pericardial patch reconstruction. Because of the debridement procedure, friable tissue at the atrioventricular junction necessitated the application of BioGlue® (CryoLife, Kennesaw, GA) between the pericardial patch and the trench created in the atrioventricular groove. Subsequently, a Size 29 St. Jude’s mechanical mitral valve prosthesis was implanted uneventfully. After separation from cardiopulmonary bypass, transesophageal echocardiographic (TEE) evaluation of the prosthetic mitral valve replacement showed normal morphology and function. No paravalvular leak was noted with respect to the annular reconstruction. However, the remainder of the examination revealed a 3-cm long filamentous structure located at the junction between the left atrial appendage and the left upper pulmonary vein (Fig. 1, please see video clip available at www.anesthesia-analgesia.org). This abnormality was clearly absent in the precardiopulmonary bypass study.Figure 1.: Midesophageal two-chamber view at 36 degrees with counterclockwise or leftward probe rotation showing a 3.0 cm filamentous structure (F) at the juncture of the left upper pulmonary vein (LUPV) and left atrial appendage (LAA). LA = left atrium; LV = left ventricle; MVP = mechanical mitral prosthesis. (Please see video clip available at www.anesthesia-analgesia.org.)Upon viewing this unusual finding, the patient was reheparinized, recannulated and cardiopulmonary bypass was reinstituted to investigate and remove this unknown and potentially harmful structure. When the left atrium was reopened, the structure in question was determined to be a strand of congealed BioGlue (Fig. 2) used during reconstruction of the mitral annulus. After the integrity of the patch was verified, the strand was removed surgically without any complication and the remainder of the perioperative course and hospital stay was uneventful.Figure 2.: Fibrin glue strand (3.0 cm) removed from left atrium.Various intracardiac foreign bodies have been reported in the literature, including a thread of lint attached to a prosthetic aortic valve (1) and fragments from a piece of gauze which embolized into a coronary artery (2). To our knowledge, this is the first case reported in which a strand of residual BioGlue was found in the left atrium after valve replacement surgery. BioGlue Surgical Adhesive is a two-component nondegradable surgical adhesive composed of purified bovine serum albumin and glutaraldehyde and is used in many surgical settings in the management of operative bleeding as well as tissue reapproximation (3,4). The use of surgical adhesives in annular decalcification and pericardial patch reconstruction has been described in the literature (5). Once the mitral annulus is decalcified, a pericardial patch is attached to the left ventricular endocardium and the adhesive is placed between the patch and the endocardium for reinforcement. In this case, the strand of glue found adhered to the posterior left atrium was likely extruded from beneath the patch used for reconstruction. If a thorough postcardiopulmonary bypass TEE examination had not been performed, the results might have been catastrophic. Given the patient’s history of atrial fibrillation as well as the fact that BioGlue is not biodegradable, the strand found in the left atrium might have embolized fragments, formed an organized thrombus with or without embolization, or compromised function of the prosthesis. Postoperative transthoracic echocardiography might not have revealed the strand because of shadowing from the prosthesis. If the strand had been detected on either the left- or right-sided circulation on a routine postoperative TEE, the patient would have required reoperation to remove the strand, as the risk of the previously mentioned complications was unacceptably high. This case illustrates the importance of a thorough and comparative pre- and postcardiopulmonary bypass TEE study during valve replacement surgery.