[HSF] Possible infected Freestyle
David Harris
drdharris at yahoo.co.uk
Tue May 1 01:02:10 EDT 2007
I agree totally with Ani.
Maybe the situation is not so bad, at any rate I would
not go back in so soon, and not after trying to
identify the microbiology. At worst he may need only
local drainage, antibiotics and wrapping the graft
with omentum. That is what is suggested by Coselli and
Safi and co in Houston for infected aortic grafts.
Send off fluid for fungal cultures, do CRP serially,
and see if it goes down spontaneously first, then with
antibiotics, and if still remaining slightly elevated
start impirical antifungals. If the CRP continues to
go up then you know you have a problem needing
surgery.
At this stage all you have is sterile pus, and no
proof of infection. you will need to do a few blood
cultures as well (just in case)
Dave Harris
--- Ani Anyanwu <anianyanwu at hotmail.com> wrote:
> 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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Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon
Suite 207
Kuils River Private Hospital,
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.
Tel +27-21-9006411
Fax +27-21-9006412 Mobile +27-83-3309587
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