[HSF] Aortic Root Abscess with aorto-RV and RA Fistulas, Acquired VSD

[Hgrmd at aol.com]

Erdinc,
  My hat is off to you with your ability to do good work under those  
conditions.  The case I did yesterday would definitely have died with that  type of 
blood bank support.  He was a 45 yo man with a history of IVDA who  presented 
with aortic staph SBE.  My partner operated on him 11 days  ago.  He found a 
chew up aortic valve.  In addition, there was a  fistula between the right 
coronary sinus and the right atrium.  From what  he described, I thought it was 
basically an infected ruptured sinus of  Valsalva.  Anyway, he did a 21mm C-E 
Magna and patched the sinus of  Valsalva with autologous pericardium.  He also 
opened the right atrium and  reportedly debrided the vegetation around the 
anteroseptal commissure of the  tricuspid valve.  In a word, the patient did 
horribly.  He remained  septic and proceeded to remain intubated, anuric, with a 
failing liver.  I  was told categorically that the guy was going to die and that 
he wasn't  salvageable.  However, I saw his mother and father at the bedside 
looking  so pitiful a couple of days ago.  I examined his status carefully.  He 
 had spiking temps, WBC of 18k and looked jaundiced.  His toes had necrosed  
from days of Levophed.  The repeat TEE showed the aortic prosthesis was OK  
and the EF was 40%.  However, there was now a large fistula between the  right 
sinus and the RA as well as the RV.  In addition, there was 3+  MR.  I decided 
to try to help him.
  Yesterday, I reopened him.  I excised the valve and the  root.  I radically 
debrided the fistula.  The process also involved  the ventricular septum.  
After adequate debridement, there was a 4 by 4 cm  hole from the right sinus, 
across the right coronary annulus, into the  septum.  Of course, the membranous 
septum was gone.  On the right  atrial side, there was a similar defect which 
included the anterior and septal  tricuspid leaflets.
  First, I closed the VSD with a patch of gluteraldehyde treated  autologous 
pericardium.  I then repaired the mitral valve with a 28mm  Physio.  Next, I 
implanted a 23mm Cryolife homograft.  Part of it's  right annular suture line 
was anchored to the patch.  Next, I placed a  similar patch on the right side 
of the heart.  Prior to completing this  suture line, I filled the space 
between the 2 patches with Bioglue.  I then  came off clamp (3 hrs and 40 minutes).  
Finally, I replaced the tricuspid  valve with a 29 mm mitral Perimount.  
Actually, finally I spent the next 3  hours of torture getting the bleeding 
stopped.  The TEE showed no leaks or  shunts with an EF of 60%.
  This morning, he is afebrile, WBD of 10, cardiac output of 6.8 on 4  mcg of 
Dobutrex and a lot of vasopressin.  I don't know if he'll make it,  but I 
think he now has a shot.
 
Hal



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