[HSF] Possible infected Freestyle

Ani Anyanwu anianyanwu at hotmail.com
Tue May 1 07:34:03 EDT 2007 

Dear Dr Martin

But he did have pus coming out the wound in patient with bioprosthetic root- wound that not (at least relatively) indicate a CT scan? 

With pus streaming out subcutaneously and a substernal collection contiguous with the aorta is it not just wishful thinking if we conclude the two are unrelated? Usually as surgeons we tend to know when there is a problem. From the way the email is structured and reading between the lines in john's email, I would be surprised if this turns out to be nothing. We can hope but hope never takes problems away, they will come back to haunt us. It is unlikely that any surgeon would be contemplating a homograft for a patient who is not even infected so I would give John the benefit of the doubt - there may be something in the story which John either knows or feels but we are not privy to, hence his concern.

It is also interesting though that several have suggested empriric antibiotics for this on one hand while in the other hand they insist it is not an infection. Either we treat it as an infection or we don't. If we chose to assume it is an infection then it needs surgical debridement. No amount of antibiotics can resolve it; indeed they may make situation worse by inducing chronicity and resistance. So to me either he is re-explored if John thinks he is septic or stop all antibiotics and observe if we don't think it is septic. There is little middle ground here.

Ani
  ----- Original Message ----- 
  From: Tdmartin2000<mailto:tdmartin2000 at aol.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Tuesday, May 01, 2007 12:22 AM
  Subject: Re: [HSF] Possible infected Freestyle


  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<mailto: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<mailto:streitman at yahoo.com> 

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