4.2.1: Inflammation
The propensity for BioGlue to cause local inflammation, with myriad resulting downstream issues, is widely reported in literature. It has been suggested that polymerised BioGlue may continue to release glutaraldehyde, which then exerts a cytotoxic effect on neighbouring tissue, inducing inflammation, oedema, and possibly necrosis.5 BioGlue-associated application site inflammation is usually sterile and characterised by the presence of inflammatory mediators with downstream clinical manifestations. In the case of a 65-year-old female who developed pericardial effusion with cardiac tamponade, following the use of BioGlue for ventricular laceration repair, Babin-Ebell et al. noted sterile microbiological findings, but with chronic granulomatous inflammatory infiltrate, likely resulting from a foreign-material reaction to BioGlue.13 Luk et al. also highlight two cases of DeBakey type I aortic dissection involving BioGlue: islands of inflammatory infiltrate (primarily macrophages, giant cells, and lymphocytes) were identified around areas where BioGlue was applied to aortic tissue.5 Further, BioGlue was also identified as causing a large, sterile abscess with an inflammatory reaction around the prosthetic aortic valve implanted in a patient with suspected bacterial endocarditis.5 It is worth highlighting that CryoLife warn against applying thick layers of BioGlue: this is said to slow proteolytic degradation of the product, which may then precipitate a sterile inflammatory response.7 In addition to localised inflammatory responses, BioGlue has also been associated with impaired aortic growth, nerve injury, and pseudoaneurysm formation.