[HSF] re: endocarditis- New pt

Fri Jan 4 08:05:55 EST 2008

My partner Phil Hess and I did a case of a infected valve conduit yesterday in a 42yr old pt who had the conduit placed 4 mo ago at an outside hospital. The bug was MSSA and there were abcesses in several areas around the dacron and a very inflamed area at the annulus in the noncoronary sinus/anterior leaflet area but no purulence at this area. It was one of the hardest redo's we've done (and that's saying a lot). We were able to debride back to good tissue in all areas and 80% of the annulus was intact without any evidence of infection. Due to her age and the difficulty of her operation we elected to put in another valve conduit. We also used some voodoo- ie we poured powdered Vancomycin on the rifampin soaked graft and we left a 18ga red rubber catheter over the graft through which we will infuse a dilute gentamicin solution for the next week. She will then get a total of 6wks of IV antibiotics and then take LIFETIME oral suppressive antibiotics. This is the protocol we have used for over 10 yrs and we see very few of these come back with recurrent endocarditis. I don't know the exact numbers but it is significant.

Tom Martin

U of Florida

Gainesville

-----Original Message-----
From: zzhoumd at pol.net
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 2 Jan 2008 11:13 pm
Subject: Re: [HSF] re: Homograft vs Freestyle for endocarditis

Thanks!

Z Zhou

Sent via BlackBerry by AT&T

-----Original Message-----
From: tdmartin2000 at aol.com

Date: Wed, 02 Jan 2008 21:36:08 
To:OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] re: Homograft vs Freestyle for endocarditis

I used to use homografts in all pts with aortic endocarditis as we felt the risk 
of recurrent endocarditis was lower that with other prostheses. The UAB 
experience that I recall seemed to have a sig lower recurrent endocarditis with 
homografts but I don't know the numbers exactly. Many places and surgeons have 
over the last 10 yrs or so focused more on radical debridement and 
reconstruction and not necessarily on the type of valve. It is currently my 
practice to use a homograft in the setting of a significant active infective 
process whre the annulus is destroyed and abcesses are present. If there is no 
abcess or the annulus is easily debrided and reconstructed then I would and have 
used some type of prosthesis. The key is agressive radical debridement to good 
tissue, at least 6 weeks of IV antibiotics and lifetime suppressive antibiotics, 
in my opinion. 

Tom Martin
U of Florida
GAinesville

-----Original Message-----
From: hgrmd at aol.com
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 2 Jan 2008 2:39 pm
Subject: Re: [HSF] re: Porcine vs pericardial for Hal and others

Dear Zhadong,

? Though I don't have recent experience with it, I plan to?do my next root 
abscess with a stentless valve.

-----Original Message-----
From: zzhoumd at pol.net
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 2 Jan 2008 1:49 pm
Subject: Re: [HSF] re: Porcine vs pericardial for Hal and others

Now I have a patient with root abscess from enteroccocus. Which valve to use, 
homograft vs freestyle bentall?

Z Zhou

Sent via BlackBerry by AT&T

-----Original Message-----
From: Ani Anyanwu <anianyanwu at hotmail.com>

Date: Wed, 2 Jan 2008 15:16:05 
To:<openheart-l at lists.hsforum.com>
Subject: RE: [HSF] re: Porcine vs pericardial for Hal and others

> > Ani,> Not to quibble, but the CCF paper you cited had more AI than AS as the 

> cause of failures in pericardial valves. > > Hal> 

Yes Hal which is why I said that the teaching pericardial fail by stenosis, 
porcine by regurgitation does not reflect the whole truth but only part of the 
truth. 

There is however an association. Just like with Bicuspid valves = aortic 
stenosis hypothesis. Most bicuspid valves will never be stenotic and most 
stenotic valves are not bicuspid but that does not mean stenosis is not a more 
frequent occurrence in bicuspid valves than tricuspid valves (as we know it is).

I will however say that our recollections are tainted by our biases. I suspect 
if you objectively looked at your data *on reop avrs* you would find very few 
cases where a porcine valve was replaced for pure stenosis (i.e. the integrity 
of the cusps was maintained). Now you have heard tom martin mention this you 
will probably start seeing the converse and noticing most porcine valves you 
explant *for structural degeneration* do calcify, leak and have torn cusps. 
Indeed part of the reason you may not have observed this is because your 
experience in rereplacing pericardial valves is comparatively limited compared 
to porcine (i think you have said in the past that you have only seen a handful 
of pericardial valves come back for degeneration, but done loads of porcine). 
Another thing possibly tainting your observation is your large volume mitral 
practice. These observations apply to the aortic position - in the mitral 
position it is rather different and porcine valves do also stenose.

Ani

> From: Hgrmd at aol.com> Date: Wed, 2 Jan 2008 07:31:44 -0500> Subject: Re: [HSF] 
re: Porcine vs pericardial for Hal and others> To: OpenHeart-L at lists.hsforum.com> 

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