A 64-year-old man with signs of severe weight loss, dyspnoea, cough and edema of the lower extremities was referred to our institute. Laboratory analysis revealed leucocytosis (12 · 7 × 109/l), raised C-reactive protein levels (64 mg/l), and decreased hemoglobin concentration (6 · 0 mmol/l). His medical history included hypertension, systemic vascular disease and hereditary hypertrophic obstructive cardiomyopathy.
Echocardiography indicated severe mitral and aortic insufficiencies secondary to partial mitral leaflet and aortic cusp destruction. Systolic anterior motion of the anterior mitral leaflet was also observed, with subsequent partial obstruction of the left ventricular outflow tract. Coronary angiography demonstrated significant left anterior descending (LAD) and anterolateral (AL) coronary artery lesions. Blood cultures were positive for Streptococcus gordonii.
We planned to graft the LAD and AL coronary arteries, partially resect the upper part of the inter-ventricular septum, following the Morrow procedure and replace both the aortic and mitral valve.
Endocarditis was suspected during surgery and a high bleeding tendency was observed. A bleeding occurred originating from an intramuscular anterolateral coronary artery, during exposure of the vessel and secondary to friable myocardial tissue (Figure 1A). This specific area became prone to diffuse bleeding. It was a combined arterial-venous bleeding. Decision was made to use the resorbable, collagen-based Hemopatch® Sealing Hemostat (Baxter International, Deerfield, IL, USA,) to achieve haemostasis without suturing.
After the AL venous anastomosis, while the patient was heparinized and on cardiopulmonary bypass (CPB), two patches were used (Figure 1B,C): one directly over the dissected area; and the second around the anastomosis after making a Y-shaped cut in the patch. The patch was placed dry and centred on the bleeding focus, after positioning we immediately applied pressure locally, using dry gauze for 2 minutes. Care was taken to avoid disruption of the locally formed clot.
Activated clotting time levels during perfusion were around 500 seconds, and 130 seconds at the end of surgery. Post-operative coagulation parameters were PT 12.1 seconds, aPTT 56 seconds, Fibrinogen 2.7, these values were corrected towards normal values within 6 hrs.
Our patient received a total of 6 units of fresh frozen plasma (300 ml each), 5 units of red blood cells (275 ml each), one unit of Thrombocytes (310 ml), 2 times 2gr tranexamic acid, and 2 grams of fibrinogen. All these products were given during surgery and within the first 6 hours on the ICU.
Fourteen hours post-surgery patient was transferred to the ward without any bleeding or other complications. Six days post surgery a routine transthoracic echocardiographic examination was performed, no pericardial effusion was seen and neither were any pseudo aneurysm formation detected, patient was discharged home with no valve anomalies, with a sinus rhythm and in good clinical condition.
