[HSF] Possible infected Freestyle

Tue May 1 17:09:24 EDT 2007

Ani,
Agree with you completely.Considering that there is a prosthetic material 
with a collection of fluid composed mainly of wbc albeit sterile any 
treatment short of removal of the graft will only prolog the problem with no 
change in the ultimate prognosis.
erdinc.

>From: "Ani Anyanwu" <anianyanwu at hotmail.com>
>Reply-To: OpenHeart-L at lists.hsforum.com
>To: <OpenHeart-L at lists.hsforum.com>
>Subject: Re: [HSF] Possible infected Freestyle
>Date: Tue, 1 May 2007 06:34:03 -0400
>
>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>
>
>   __________________________________________________
>   Do You Yahoo!?
>   Tired of spam?  Yahoo! Mail has the best spam protection around
>   http://mail.yahoo.com<http://mail.yahoo.com/>
>   _______________________________________________
>   OpenHeart-L mailing list
>
>   Send postings to:
>   OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>
>   To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>   
>http://mmp.cjp.com/mailman/listinfo/openheart-l<http://mmp.cjp.com/mailman/listinfo/openheart-l>
>
>   All messages transmitted by the OpenHeart-L are subject to the policies 
>and
>   disclaimers posted at:
>   http://www.hsforum.com/listdisclaim<http://www.hsforum.com/listdisclaim>
>   -----------------------------------------
>   _______________________________________________
>   OpenHeart-L mailing list
>
>   Send postings to:
>    OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>
>   To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>   
>http://mmp.cjp.com/mailman/listinfo/openheart-l<http://mmp.cjp.com/mailman/listinfo/openheart-l>
>
>   All messages transmitted by the OpenHeart-L are subject to the policies 
>and
>   disclaimers posted at:
>   http://www.hsforum.com/listdisclaim<http://www.hsforum.com/listdisclaim>
>   -----------------------------------------
>_______________________________________________
>OpenHeart-L mailing list
>
>Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
>To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>http://mmp.cjp.com/mailman/listinfo/openheart-l
>
>All messages transmitted by the OpenHeart-L are subject to the policies and
>disclaimers posted at:
>http://www.hsforum.com/listdisclaim
>-----------------------------------------