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

[Mitch Lirtzman]

Brilliant work, Hal. Is that the clanging together of cojones that I hear 
all the way to Louisiana?At 06:55 AM 3/22/2007, you wrote:
>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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