AW: [HSF] SBE and the Indications for Surgery

[Tea Acuff]

I would have given the usual 6 weeks for endocarditis, but I don't have that paper that Hal is always asking for.
Tea


----- Original Message ----
From: Mitch Lirtzman <drmitch at cox.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, February 5, 2007 6:51:43 PM
Subject: Re: AW: [HSF] SBE and the Indications for Surgery


May I respectfully ask a follow up question? I had a similar patient with 
staph aortic endocarditis. No emboli. Severe AI w/o failure. Decent sized 
vegetation. Blood cultures had become neg. on appropriate therapy. 
AVR...bada bing, bada bum. Easy recovery. NOW...do we place him on 
suppressive Abx? If so How long? BTW, I did, for 3 mos, just to make myself 
feel better. The ID guy didn't commit to definitive therapy. Thanks in 
advance for the lessons.
Mitch LirtzmanAt 01:23 AM 2/5/2007, you wrote:
>Ed,
>I agree, most of this complicate cases have splenic embolus. We have made a
>nice number of splenectomies on them. The mortality is very high when the
>patients have already cerebral insult.
>Roberto
>
>-----Ursprüngliche Nachricht-----
>Von: openheart-l-bounces at lists.hsforum.com
>[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Edward Bender
>Gesendet: Montag, 5. Februar 2007 00:58
>An: OpenHeart-L at lists.hsforum.com
>Betreff: Re: [HSF] SBE and the Indications for Surgery
>
>Hal:
>You know as well as anyone on this list that old literature poisons
>current practice.  The classic indications for surgery are heart
>failure, embolus, or uncontrolled sepsis.  These were developed in an
>era of high mortality rates for valve surgery, not to mention valve
>surgery in a septic patient in failure.  Current literature claims a
>10% embolic rate when a vegetation is 15mm or more diameter.  We also
>know that there are silent emboli occurring more frequently.  I would
>not right off this patient yet.  Get CT of abdomen (spenic embolus?),
>aggressive antibiotics, rehab.  In a couple of weeks she may be
>salvageable.  The family will probably do whatever you say, so be
>careful.  If she does improve neurologically, proceed without waiting.
>Also, be kind to your ID guy. He probably feels bad enough already.
>
>PS. I give kudos to you stamina under pressure Sunday night.
>
>Ed Bender, MD
>
>On Feb 4, 2007, at 4:38 PM, Hgrmd at aol.com wrote:
>
> > Dear Members,
> >   About 3 months ago, I was asked to see an 80 yo fairly frail
> > lady  with
> > mitral staph SBE.  By the time I saw her, she was afebrile with mild
> > leukocytosis.  The coronaries were normal by cath and the EF was
> > 50%.   TEE revealed a 15
> > mm vegetation on the posterior leaflet with moderate MR.   There
> > were no
> > overt signs of CHF.   A t the time I suggested surgery  based on
> > the large
> > vegetation.  I was all set to operate, when, on the day  before,
> > the ID doc stepped
> > in and emphatically stated that surgery was not  indicated.  He
> > felt that
> > sepsis appeared to be controlled with anitibiotics  alone and that
> > there were no
> > indications for surgery.  He also told that to  the patient and her
> > son.  I
> > backed off and let them have their way.
> >   Last Friday, I was reconsulted on this patient.  She had
> > represented with
> > a large right hemispheric CVA.  She was now blind in the  left eye
> > and unable
> > to move the left side.  She's screwed.   Transthoracic echo now
> > revealed
> > severe MR with poor visualization of the  posterior leaflet. The
> > family told me
> > they wished they had listened to me.   The point is that large
> > vegetations alone
> > are current indications for surgical  intervention.  Anybody disagree?
> > Hal
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