[HSF] Possible infected Freestyle

[Tdmartin2000]

John
Great case- this is what you get for getting the CT scan. It doesn't surprise me to have fluid around the graft. If you were to CT all pts with a root ascending repair at 8 wks I would expect a large number to have fluid around their graft. 
If you have no bacteria on gram stain and no growth and no evidence of any suture line breakdown, I would do nothing and repeat the CT scan in 2 to 4 wks. If it is infected he will declare himself.
If you are forced to do anything surgically then at this point in time I would only explore his mediastinum, pulse lavage, and if there is any question of infection then put some omentum over/around the root. I would not redo his root unless there was some type of breakdown/pseudoaneurysm.
I am assuming from your post that there was no direct communication between the substernal and subcu fluid collections.
Let us know what you decide.

Tom Martin
U of Florida
Gainesville




In a message dated 04/30/07 00:42:39 Eastern Daylight Time, streitman at yahoo.com writes:
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 

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