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

[erdinç naseri]

Hal,Real extensive surgery. very complicated operation. the case would ended 
in mortality if it was not performed in a center with very strong and 
sophisticated scientific structure and in very experienced hands in this 
type of operations.
erdinc



>From: Mitch Lirtzman <drmitch at cox.net>
>Reply-To: OpenHeart-L at lists.hsforum.com
>To: OpenHeart-L at lists.hsforum.com
>Subject: Re: [HSF] Aortic Root Abscess with aorto-RV and RA 
>Fistulas,Acquired VSD
>Date: Thu, 22 Mar 2007 19:14:12 -0500
>
>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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