[HSF] re: endocarditis- New pt
tdmartin2000 at aol.com
tdmartin2000 at aol.com
Fri Jan 4 21:55:31 EST 2008
Z
We actually have quite a bit of experience with just such a pt. By that I mean somewhere in the 15 to 20 pts over the last 5 to 10 yrs. We are currently looking at the numbers. We have had enough experience to call the operation a "bomb". I tell the residents that you debride back enough so that it looks like a bomb went off and then you start piecing it together. We also use bovine pericardium to reconstruct things like the membranous septum, RV outflow tract, medial wall of the R atrium, dome of the left atrium, atrial septum and whatever else might be involved. I would hazard to guess that our survival is somewhere in the 85% range. The ischemic times are usually really long (3 to 4 hrs) and pump times are really long (5 to 7) hrs depending on how much of a bomb goes off. I thing the intraoperative key is to realize that it is going to take long and to protect the heart. I am a old timer and I still use cold oxygentated crystalloid cardioplegia and for these cases I cool to 25 degrees to make sure I keep the heart cold. I even put crushed ice into the heart. Most of the time we don't have a tremendously difficult time with myocardial function, but coagulopathies are routine. In the post aprotinin era we don't hesitate to use recombinant factor 7.
Tom
-----Original Message-----
From: zzhoumd at pol.net
To: OpenHeart-L at lists.hsforum.com
Sent: Fri, 4 Jan 2008 4:54 pm
Subject: Re: [HSF] re: endocarditis- New pt
Tom,
My redo patient with enterococcus root abscess did not survive the surgery. He
developed sepsis and AV block that I had to operate on him emergently yesterday.
I could not get his blood presure up after anesthesia. He then went to asystole
after I open the chest. I was able to pace him with a temporary wire. After I
removed old st jude valve, I saw multiple abscess below the annulus and the
outflow tract completely fell apart from the annulus. After through debriment, I
used pericardial patch reconstructed the annulus, then placed full root
freestyle valve which was re-enforced with a felt. I also repleced mitral valve
and did 3 grafts. I had to redo the freestyle valve due to bleeding. He expired
this am from multi organ failure, profund acidosis and DIC.
What is your experience with such root abscess with complete seperation of the
outflow tract from aorta with a gap about 1 cm. How do you repair them.
Thanks!
Z Zhou
Sent via BlackBerry by AT&T
-----Original Message-----
From: tdmartin2000 at aol.com
Date: Fri, 04 Jan 2008 08:05:55
To:OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] re: endocarditis- New pt
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 hav
e 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>
CC: > > > **************************************See AOL's top rated recipes >
(http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004)>_______________________________________________>
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> -----------------------------------------
_________________________________________________________________
Free games, great prizes - get gaming at Gamesbox.
http://www.searchgamesbox.com_______________________________________________
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
-----------------------------------------
_______________________________________________
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
-----------------------------------------
________________________________________________________________________
More new features than ever. Check out the new AOL Mail ! -
http://webmail.aol.com
_______________________________________________
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
-----------------------------------------
________________________________________________________________________
More new features than ever. Check out the new AOL Mail ! -
http://webmail.aol.com
_______________________________________________
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
-----------------------------------------
_______________________________________________
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
-----------------------------------------
________________________________________________________________________
More new features than ever. Check out the new AOL Mail ! -
http://webmail.aol.com
_______________________________________________
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
-----------------------------------------
_______________________________________________
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
-----------------------------------------
________________________________________________________________________
More new features than ever. Check out the new AOL Mail ! - http://webmail.aol.com
More information about the OpenHeart-L
mailing list