[HSF] Possible infected Freestyle

Tea Acuff tacuff at swbell.net
Mon Apr 30 19:54:06 EDT 2007 

John,
This is my reservation of adding a more "complete" solution to an associated process in the absence of clear need to do the same. If one looks at the costs and morbidty of screening and treating all lung nodules or all "small to moderate" AAA is staggerring. In this case of adding a "root", we will exact real sufferring for potential benefit. I am not saying that you errorred in doing the root, but clearly the management of this patient would have a better prognosis with a simple aortotomy. (Unless you also rountinely use a pack of pledgets to close the same.) The best surgery avoids the need for "more" even if you can easily do more. Or as I say over and over less is often (not always) more.

Welcome to the club. Now we can get the real scoop on Tom. If you are really a youngster the best thing for both you and the patient may be to send the patient one state south.

tea


----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, April 30, 2007 5:10:57 AM
Subject: Re: [HSF] Possible infected Freestyle


A reoperative root replacement 2 months postop in an 80 year old with patent grafts is a difficult operation with high mortality so not one to undertake unless absolutely indicated (to save life). Even surgery just to drain the collection is not straightforward. 
Have you checked for fungus? Presentations like this are typical for fungal abscess. Also did you have any post-operative imaging - was there a known collection before? Did he have a lot of post-operative bleeding? I presume the CT was done with contrast and there is no pseudoaneurysm?

When you say though that radiologist sampled substernal fluid, is the collection round aorta contiguous with a substernal collection or does he have two separate collections? Not an easy case but I suspect you may be dealing with a fungus or a less fastidious bacterium especially if he is immunosuppressed or debilitated. While it is nice to hope that this is not an infection I agree with you that this has to be the assumption until proven otherwise (which is near impossible to prove).

Personally in this patient (assuming no pseudoaneurysm) I would favor opening up and draining the abscess, leave open for a few days with vacuum dressing and then when clean get plastic colleague to transpose a pectoral muscle over the root then close sternum. We have used this method successfully for abscess around dacron grafts (without root rereplacement). Doing a homograft may be ideal but you need a live patient at the end.

Welcome to the forum - I am quite junior too and have learnt a lot here, I am sure you will too. Best of luck!

Ani 
  ----- Original Message ----- 
  From: john streitman<mailto:streitman at yahoo.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Monday, April 30, 2007 12:39 AM
  Subject: [HSF] Possible infected Freestyle


  HS forum members:

  I am new to the forum (recent grad from UF-2006 (hi
  Tom) but have been reading many of the threads and
  finally have a case I would like some input on.  Three
  months ago I performed a Freestyle root (25mm)/ 4V
  CABG on an 80 y/o male with severe AS/ASCAD.  I
  started out doing an AVR/CABG and could not get a 25
  mosaic to sit appopriately and in trying to do so tore
  the aorta b/t the left main ostium and the annulus. 
  Instead of trying to repair this and downsize the
  valve choice or enlarge an injured root, I elected to
  proceed with a 25-Freestyle and he did amazingly well
  (solid 80 y/o protoplasm).  He was seen at 4 weeks and
  was d/c back to his cardiologist.  Now 8 weeks out he
  came to my office with a small midsternal abscess
  (less that 1 cm) which I thought was just a suture
  abscess.  I proceeded with CT scan which showed fluid
  around his root/asc aorta.  The sternum appears well
  healed and is clinically stable.  No fever, normal WBC
  and feels well.  I opened the abscess to find pus and
  on GS there was no bact with many WBC's.  Culture neg
  for >72 hrs on no abx prior.  I was able to get a
  radiologist to sample the substernal fluid and this
  too had many WBC's w/o bacteria and so far (48 hrs)
  has been culture negative.  He remains afebrile with a
  normal WBC.  He will get a TEE tomorrow.  ID has seen
  him and feels he needs root replacement and I have
  several homografts coming in.  I am prepared to
  replace this root but is this the right answer?  Any
  other ideas about how to determine what to do?  Look
  forward to your input.

  John

  John E Streitman, M.D.
  Cardiovascular Surgeon
  Pinehurst Surgical
  streitman at yahoo.com<mailto:streitman at yahoo.com>

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