Application of Cyanoacrylate Adhesive (Krazy Glue) in Critical Cardiac Injuries

Application of Cyanoacrylate Adhesive (Krazy Glue) in Critical Cardiac Injuries Dennis P. East-man, Francis Robicsek The Cerulimzs Heart Institute, Charlotte, NC, USA Background and aims of the study: Although small lacerations of the myocardium may be repaired easi- ly using conventional methods, larger tears or rup- tures, especially if they occur in infarcted myocardial tissue, may create formidable technical challenges. Described is a method for applying sutureless peri- cardial patches for control of hemorrhage. Methods: A sutureless pericardial patch was glued to the myocardium with commercially available house- hold cyanoacrylate (Krazy Glue) in seven patients. Results: No patient in this series developed any evi- dence of mediastinal infection as a result of this tech- nique. Six patients were discharged home without Although small lacerations of the myocardium may be repaired easily using conventional methods, larger tears or ruptures - especially if they occur in infarcted tissue - may present formidable technical challenges. Padro et al. in Spain reported on a sutureless technique for applying a Teflon patch for cardiac rupture with a surgical glue (cyanoacrylate) (1) Robicsek et al. pre- sented early experience with Krazy Glue in cardiac surgery (2). The present study describes a method for applying sutureless pericardial patches for the control of hemorrhage, and summarizes the authors’ earlier experiences and more recent results of the clinical application of this technique. Clinical material and methods Patients The use of this technique has been reported previ- ously in four patients (2). The first patient was a 78- year-old woman who underwent aortic valve replace- Presented at the "Use ol rcncardiunt in Cardiac Surgery" Sympo- sium, Landon, 2nd~4th October 1997 Address for correspondence: Dennis rasnnan MD, mm Blythe Blvd., Suite am, Charlotte, NC 23103, USA any long-term sequelae noted. One patient developed reinfarction and died of arrhythmia two weeks fol- lowing surgery, Autopsy revealed that the laceration had healed and that the patch was closely adherent. Bacteriology studies revealed that different brands of cyanoacrylate are not only bacterium-free but also exhibit a bactericidal effect. Cimclilsians: Sutureless pericardial patches fastened to the myocardium with cyanoacrylate glue to control hemorrhage under critical situations were easy to apply, safe and effective in this series of patients. The Iourrlal of Heart Valve Disease 1998,7172-74 ment. Following closure of the aortotomy it became evident that, due to manipulations of the ascending aorta, partial aortic-ventricular disruption had occurred. This resulted in severe hemorrhage which was uncontrollable with sutures The second patient was a 62-year-old woman who developed cardiac tamponade due to spontaneous left ventricular rupture five days following acute myocar- dial infarction. Sutures were unable to control the hem- orrhage due to the friability of the tissue. The third patient was a 15-year-old boy who suffered a through-and-through gunshot wound to the posteri- or aspect of the left ventricle. The bullet destroyed a major obtuse marginal branch of the circumflex coro- nary artery and the wounds were close to another large branch, thus preventing suture closure of the defects. The fourth patient was a 78-year-old man who devel- oped cardiac tamponade following perforation of the right ventricle by a temporary pacemaker electrode. He was initially managed with pericardiocentesis but this resulted in a second laceration to the infarcted anterior right ventricular wall. This friable tissue would not hold sutures for control of hemorrhage. Over the past several months we have used this tech- nique in another three critical circumstances. The first case was a 52-year-old woman who suffered catheter ® Copyright by ICR Publishers 1998 ]Heart Valve DIS Vol 7. No. l January 1993 Figure 1; Cnrdinc injury m infnrcred, friable myocnrtiium. perforation of the infarcted right ventricular myocardi- um. Pledgeted sutures failed to control the hemor- rhage. The second was a 64-year-old male who suffered a right ventricular injury while undergoing redo ster- notomy for recurrent coronary artery disease. The injury was initially repaired with pledgeted sutures. However, the patient was re-explored for bleeding and the right ventricular repair had disrupted, the area being to friable for suture control. The final case was a 62-year-old male undergoing redo double valve replacement. During the course of surgery he sustained a rupture of the coronary sinus from the retrograde car- dioplegia cannula. This was recognized following valve implantation, making suture repair impractical due to exposure. Surgical technique In all patients the injury was repaired in a similar manner. Cardiopulmonary bypass was initiated when mry.c,...,. Figure 2.- TuH1po1'm1y control 0}‘ bleeding with laws: sutures Cyimmzcrylntes in cardiac injuries 73 D. P. Eastman, F. Rabicsek Figure 3' Ill]ECll0ll Dfglue imrlrr pzricnnilal patch for defini- tive cmxtrnl of bleeding. necessary with regard to the clinical situation. Bleeding was brought under control as much as possible with approximating sutures and pressure, after which a large pericardial patch was placed over the entire involved area. Cyanoacrylate glue (3-4 ml) was then injected under the patch, after which the patch was manually compressed against the area for 1-2 minutes (Figs. 1-3). Results No patient in this series developed any evidence of mediastinal infection as a result of this technique. Six of the seven patients were discharged home without any long-term sequelae. One patient developed reinfarc- tion and died of arrhythmia two weeks following surgery. Autopsy revealed that the laceration had healed and that the patch was densely adherent to the myocardium. Although the glue utilized in these cases was applied under sterile conditions, it was not sterilized prior to its use by any of the usual means. This prompted our insti- hition in a previous report to conduct bacteriologic studies on several commercially available brands of cyanoacrylate (2). These revealed that not only are sev- eral brands of commercially available cyanoacrylate bacterium-f-ree, but that they also exhibit a bactericidal effect. Discussion Following initial reports regarding the use of cyano- acrylates in surgery, numerous applications have been described. Cyanoacrylate glue has been used success- fully in all types of surgical procedures from comeal procedures, plastics procedures, orthopedic surgery, attaching skin grafts, and to skin closure techniques (3- 7). Moreover, it has recently been described in the car- 74 Cyzmoacrylates in cardiac injuries D. P, Eastman, F. Robicsck diothoracic literature for the closure of uncontrollable air leaks (5), and for the repair of left ventricular free wall rupture (9). Reservations regarding the expanded use of such glues in surgery have been expressed because of their possible histotoxicity (10-12), a situa- tion which may be due to degradation of the material in vivo, yielding formaldehyde. Studies have shown that Cyanoacrylates which are degraded in tissues are eliminated in the urine and feces (10). Neurotoxicity, a pronounced inflammatory response and sarcoma induction have been demonstrated in animal studies, but no such effects have been demonstrated in human subjects (11-13). Formaldehyde formation may account for the demonstrated antibacterial effects noted in the many different cyanoacrylate preparations. We con- clude’ from our experience that the use of sutureless pericardial patches for the control of hemorrhage has proven safe and effective. It is our opinion that, under critical conditions, the use of a sutureless pericardial patch fastened to the myocardium with cyanoacrylate glue is not only lifesaving, but is also a safe and easy technique to apply. References 1. Padro JM, Mesa IM, Silvestre ]. Subacute cardiac rup- ture: Repair with a sutureless technique, Ann Thorac Surg 1993:5520-24 2. Robicsek FR, Reilly JP, Marroum MC. The use of cyanoacrylate adhesive (Krazy Glue) in cardiac surgery, J Card Surg 1994;9(3):353—355 3. Alio IL, Mulet ME, Garcia IC. 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