Off-pump epicardial tissue sealing--a novel method for atrioventricular disruption complicating mitral valve procedures.

Background: Atrioventricular disruption (AVD) is a rare (1%-2%) but fatal complication after mitral valve procedures; the intraoperative mortality is more than 50% despite the current standard procedure of surgical closure of the defect. We compared the outcome of 9 patients with intraoperative AV disruption, 4 being surgically treated on-pump and 5 receiving epicardial tissue sealing off-pump.
Methods: Between March 1998 and May 2002 a total of 9 patients presented with AV disruption intraoperative. The first 4 patients were treated with surgical repair on-pump by reconstruction of the defects with patch or buttressed suture. The second series of 5 patients were treated with a biodegradable collagen system with fibrinogen-based coating off-pump. Three to six layers were placed over the bleeding site with manual pressure for 30-60 minutes on the beating heart until bleeding was stopped. Cell saved blood was retransfused.
Results: In the on-pump surgical repair group 3 patients (75%) died within the first day after repair either because of persistent bleeding or cardiac tamponade. One patient survived at 30 days and 1 year. In the off-pump tissue sealing group 30 days and 1 year survival was 100%. Postoperative echocardiography showed normal left ventricular (LV) function with no regional wall motion abnormalities.
Conclusions: Our data show that epicardial tissue sealing off-pump results in successful termination of bleeding from AVD and considerably improves survival when compared with the standard procedure. Because of this tremendous improvement in patient survival we now consider this technique as standard therapy for AV disruption in our center.