[HSF] Antibiotics for endocarditis
Michael Firstenberg
msfirst at gmail.com
Sun Feb 8 20:04:37 EST 2009
Tea's comments say it all - as they usually do.
of course, a few other comments and thoughts come to mind
Just curious, what did you do with the heart?
(or shall I say, it is no wonder you wife made you clean your
basement.......)
On Feb 8, 2009, at 5:28 PM, Rwmfglycar at aol.com wrote:
> I had more than one case of fungal prosthetic valve infection which
> was apparently?cured by conventional surgery and a limited course of
> appropriate antibiotics. I will?summarise one of these cases (I
> think I?presented this case before but HSF memories are generally
> short).
> Operation 1. Synthetic aortic?leaflet valve placed by Muller in the
> 60's.
> Operation 2. Synthetic valve broke. Replaced by Muller with a
> Mcgovern/Cromie sutureless valve.
> Operation 3. I was called to see patient?in neighbouring hospital on
> Thanksgiving day early 70's. On chest Xray valve sitting on its side
> in Left Ventricle. Patient transferred directly to Einstein OR and
> after splashing skin with betadine,?put on bypass. Replaced with a
> University of Cape Town mechanical aortic valve. Running fever for 3
> weeks postop. Blood cultures positive for fungus. Started on IV
> amphotericin. Went into pulmonary edema by end of first?IV
> amphotericin dose.?No clinical evidence of aortic valve
> insufficiency. Same thing happened the second and third doses,?
> which we administered very slowly.?We realised this could be?a
> manifestation of allergy to amphotericin and decided on reoperation.
> Operation 4. Reoperated. Fungal vegetations confined to valve sewing
> ring. Valve replaced. Patient placed on oral antifungal agent for?8
> wks. Patient who was homosexual liked to hold my hand on rounds.
> BIC's (Bronx Irish Catholic Nurses) disapproved strongly. Became
> rapidly afebrile and was discharged apparently cured. But left
> ventricle by now dlated and myopathic.
> Three years later went on a trip to Russia. Died there suddenly. Two
> to three months later I received a box from Moscow. It contained my
> patient's heart with his valve in place.?It was well healed and?was
> entirely free of any evidence of infection. I regard this case as
> adequate proof of cure of a case of fungal prosthetic valve
> infection by surgery and a limited course of antibiotics.
> Bob
>
>> Roberto> Date: Sun, 8 Feb 2009 18:31:27 +0530> Subject: Re: [HSF] >
>> Cabrol patch for massive hemorrhage> From: prasannasimha at gmail.com>
>> > To: OpenHeart-L at lists.hsforum.com> CC: > > Million dollar
>> question > when to stop. If it is fungus, it would be> for a
>> lifetime.
>
>
>
> -----Original Message-----
> From: Michael Firstenberg <msfirst at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sun, 8 Feb 2009 7:09 pm
> Subject: [HSF] Antibiotics for endocarditis
>
>
> The six week rule for endocarditis - if you talk with most good ID
> people - is as much voodoo as anything else that we or they do. Does
> that mean 5 1/2 weeks is the curse of death and 7 weeks will result
> in catastrophic C. dff or the start of global epidemic of some multi-
> drug resistant organism (I am currently following 10 year/old
> Bentall in a disaster patient who has been on abx forever for
> "strands on his aortic valve" - not convinced he has endocarditis, I
> declared him inoperable, but yet I get re-consulted every could of
> months for the past year or so). Having said that, I am not sure
> life-long antibiotics is such a bad idea - particularly in some of
> these patients, it probably will not be for that long.?
> ?
> -michael?
> ?
> ?
> On Feb 8, 2009, at 11:47 AM, Roberto Battellini wrote:?
> ?
>> ?
>> Our infectologist indicated 6 weeks i.v. and one year per os to one
>> > case.?
>> (not yet finished)?
>> Roberto> Date: Sun, 8 Feb 2009 18:31:27 +0530> Subject: Re: [HSF] >
>> Cabrol patch for massive hemorrhage> From: prasannasimha at gmail.com>
>> > To: OpenHeart-L at lists.hsforum.com> CC: > > Million dollar
>> question > when to stop. If it is fungus, it would be> for a
>> lifetime. Minimum > of 6-8 weeks . I have one case of endocarditis>
>> with huge > vegetations (remember the iliac pseudoaneurysm girl
>> who> ruptured. > She was afebrile and completed her antibiotic
>> course and had> normal > counts and was afebrile and I diod her
>> Echo and found> > hugevegetations (I have got to post the photos)
>> which was > prolapsing> into the mitral valve like a myxoma. I did
>> her MVR and > the excised> vegetations. The center of the
>> vegetation showed > basophilic bacterial> colonies on histopath. I
>> also took a bit of > the center of the specimen> , triturated it
>> and injected it into a > Bactec culture bottle and that> is
>> posiitve despite negative > cultures.That has come positive for>
>> staphylococcus. She is a
> febrile > but I have placed her on Rifampicin> and ciprofloxacin
> (Based on > cultures)and now am wondering how long ?> At least for 8
> weeks . I > just hope her prosthesis doesnt get infected.> (I
> couldnt repair the > valve). How long to members give antibioitcs
> for> such patients ?> > Prasanna> > On Sun, Feb 8, 2009 at 6:11 PM,
> John Schor <johnschor at mac.com> > wrote:> > If the RA to Cabrol patch
> remains open (and I have seen > them do so with high> > enough flows
> to be a real left to right > shunt) then it can be closed later> >
> with an "ASD" type closure > device. On the arterial side, if an
> angiogram> > shows a sizeable > aortic pseudoaneurysm, as alluded to
> by Hal, the same is> > also > possible in terms of percutaneous
> closure. I have also pondered the > use> > of a thoracic endograft
> to cover such a hole.......> > Is 6-8 > weeks of antibiotics too
> short a course? Is lifetime suppression> > > necessary?What organism
> do you suppress? These cases make me > nervous.> > By t
> he way, don't be so hard on yourself....you have > clearly saved a y
>
> oung> > man's life. Great job.> > John> >> > John > Schor, MD> >
> Thoracic and Cardiovascular Surgery> > Verde Valley > Medical
> Center> > Cottonwood, AZ> > Tel: 928-649-2584> >> > On Feb > 7,
> 2009, at 8:04 PM, Prasanna Simha M wrote:> >> >> Young male had >
> undergone an uneventful aortic valve replacement for> >> rheumatic >
> heart disease in November. Echo done in December was normal. In> >>
> > January the patient came with mild fever with breathlessness and >
> was> >> examined by my friend who noticed and early diastolic murmur
> > and> >> echocardiography showed rocking of the valve with major >
> dehiscence.> >> Cultures> >> were drawn and a presumptive diagnosis
> > of early prosthetic endocarditis> >> was> >> done.I was invited by
> > my friend to do the surgery.> >> Counts were raised but culture >
> reports were awaited but due to progressive> >> increase in rocking
> > emergent surgery was planned.> >> Case was done under femoro
> femoral > CPB with vacuum assist . Initial> >> sternot
> omy was done after rapid > retrograde priming of the circuit to> >>
> allow> >> deliberate > hypotension and later femoral CPB was
> instituted> >> Patient chest > was opened uneventfully .As exp[ected
> in active endocarditis> >> > Oozing ab initio was present and we had
> a Tranexamic acid infusion > going> >> on.> >> Previous pericardium
> was not closed but the > mediastinal structures was one> >> rock of
> unidentifiable > tissue.Both pleurae were opened Dissection was
> done> >> and a > vertical tubular structure was identified (aorta)
> and below which a> > >> venous structure (RA) was dissected. The
> "aorta" looked a little > small> >> but> >> it was recalled that the
> aorta was small. This > structure was noted low> >> done> >> at the
> level of 4th > interocostal space. Arrangements were made to do a>
> >> transtoric > exposure and patient was cooled and LV was vented
> via a> >> transRV> > >> transeptal needle . I opened the aorta after
> clamping and was > shocked to> >> note a massive eg
> ress and realized that something was > wrong, inserted a> >> Foley a
>
> nd closed the wound. What I had injured > was the innominate artery>
> >> aorta junction (the incision was > actually recognized to be the
> base of the> >> aorta) and vein and > this was repaired. The
> innominate vein (which had that> >> time > assumed as the blue
> structure as RA had been opened and this needed> > >> dividing and
> repair. Incidentally it was stuck over the RA. Both > the root>
> >> ,> >> innominate vessels and RA had been dragged down > together
> by fibrosis. I> >> had> >> no CT but I wish I did at that > time !!>
> >> After recovering from that mishap and feeling pretty > foolish
> dissected> >> further down and got hold of the aorta and did > a
> transtoric incision which> >> extended on to the main aorta and it >
> revealed a floating valve with> >> nearly 2/3rds the annulus had >
> dehisced. After debriding and deroofing all> >> abscesses etc it was
> > decided that a root replacement was not required. I> >> tanned the
> > area of annular attachment and residual abscess wall f
> irst with> >> > 2> >> % glutaraldehyde followed by 0.5 %
> Glutaraldehyde to both > sterilize and> >> stiffen tissues following
> which a 23 Biocor valve > was implanted. We> >> closed> >> the aorta
> with not much difficulty. > Post clamp release we noted persistent>
> >> bleeding from suture line > s which we assumed would stop with
> protamine.> >> The> >> the aorta > started tearing and a vertical
> tear from the aortic vent site> >> > occurred and then progressively
> required multiple stitches etc etc.> > >> Tissues> >> were friable
> and now a decision was taken to either > replace the root or an> >>
> alternative. Since I had done minimal > dissection and there was
> rock like> >> vascular adhesions root > replacement would be a
> challenge. We then decided> >> to> >> > reapproximate all divided
> tissues as a wrap which fairly controlled> > >> hemorrhage When we
> went off CPB I was not happy with hemostasis > so we went> >> back
> on CPB and placed a Cabrol type patch which was > fistulated t
> o the RA> >> via 5 mm punch. This allowed good > hemostasis with no
>
> further bleeding and> >> patient needed > Vasopressin noradrenalin
> to wean off CPB as he was> >> vasoplegic as > expected due to his
> septic state.> >> Even his femoral cannulation > sites were oozing a
> lot. I placed a> >> phenylephrine - tranexamic > acid -aprotinin
> irrigation catheter as there> >> was> >> no surgical > site bleeding
> but was generally oozing everywhere and was> >> > worried that he
> would require major transfusions which i would like > to> >> reduce
> in a septic patient.> >> Patient had delayed wakening > Creatinine
> bump which was managed> >> conservatively . He had no > bleeding and
> was discharged after 2 weeks. His> >> cultures have > unfortunately
> come negative but he will be on 6-8 weeks of> >> > antibiotics> >>
> Cabrol patch fistulation has been well described in > the past to
> allow> >> hemorrhage to be self contained. Usually these > close
> down after a few> >> weeks> >> (Current predischarge echo > still
> shows some fistulation)> >> I have done this 3 times
> in the > past for uncontrollable hemorrhage by> >> creating a
> closed area and > placing a patch (either pericardium goretex or> >>
> in> >> this case > a split hemashiedl graft) to fistulate to the RA.
> I think Tomas> >> > Salerno has also published descriptions of these
> (including one > recently)> >> and the original description seems to
> be from Texas > heart Journal where a> >> Cabrol type patch was used
> deliberately > for uncontrollable hemorrhage.It> >> seems a good
> option to use when > you are in a "sticky wicket" though people> >>
> may have concerns but > it has been life saing whenever I have used
> it. An> >> alternative > is to splay a graft partially and attach
> the closed end to the> >> > RA or a graft from the patch to the
> innominate vein or RA.> >> > Comments (and still feeling foolish
> over the innominate vessel > injury).> >> Any> >> further tips
> tricks and EBM and non EBM > observations !!> >>> >> --> >> Prasanna
> Simha M> >> <Cabrol type > patch atrial fistula> >> >
> eml.jpg>_______________________________________________> >> > OpenH
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