Infected Teflon felt strip-paracardiac abscess after Dor’s procedure

Infected Teflon felt strip-paracardiac abscess after Dor’s procedure Abstract Foreign material used for reconstructing or suturing the cardiac chambers carries the risk of infection. When such a scenario is encountered, it is better to be aggressive in removing the infected source surgically, as conservative management will most often result in recurrence. Herein, we present an unusual case of infected prosthetic material after cardiac surgery that was managed surgically. This case reminds us of the surgical principle of eradicating the source of infection, which should be given priority. Teflon, Infection, Paracardiac, Abscess INTRODUCTION A 72-year-old hypertensive male presented with a chronic sinus and a granuloma in the epigastric region (Fig. 1) of 6 months. He had undergone coronary artery bypass grafting (CABG) surgery × 5 grafts + Dor’s procedure + left ventricle thrombectomy + infarctectomy 7 years ago through a median sternotomy in another institute. The patient’s medical history was suggestive of repeated surgical interventions for sternal instability. An incision and drainage for a swelling of acute onset in the epigastric region was performed 6 months earlier, which resulted in a chronic sinus. On examination, a pulsatile swelling (3 × 2 cm) was observed in the epigastric region surrounding the sinus (Video 1). His sternal wound was stable otherwise. His blood investigations were unremarkable, and there was no reported history of immunosuppression. A computed tomography (CT) scan of the chest showed a paracardiac abscess measuring 10 cm × 10 cm posterolateral to the left ventricle (Fig. 2) communicating to the epigastric region. It was decided to explore the abscess surgically with all precautions. Video 1 On table transmitted pulsations over the granuloma. Video 1 On table transmitted pulsations over the granuloma. Close Figure 1: View largeDownload slide Pulsatile granuloma with sternotomy scar. Figure 1: View largeDownload slide Pulsatile granuloma with sternotomy scar. Figure 2: View largeDownload slide A computed tomography scan showing a paracardiac abscess. Figure 2: View largeDownload slide A computed tomography scan showing a paracardiac abscess. The chest was entered through a left anterolateral thoracotomy with preparation of groin vessel cannulation for any eventuality. The left lung was released. Needle aspiration from the pericardial surface revealed purulent material. The sac was opened, and approximately 300 ml of pus was evacuated. The material was then sent for bacteriology. Abscess cavity loculations were opened, and sinus tract to the epigastric region was defined. Felt strips were found on the surface of heart and these felt strips were excised carefully in a piece meal manner. At every point, care was taken to ensure that no felt was ripped off, relying much on the intracavitary prosthetic material used in the primary procedure to afford safety from major bleeding. The tag was held by a gentle traction, allowing the heart beat to slowly dislodge the felt and the previous Prolene suture material. The abscess cavity was deroofed. The surrounding thymic and fatty tissues were mobilized as a pedicle and were utilized to fill the cavity. The foreign body granuloma site was excised, and the wound was closed in layers with a drain. The patient had an uneventful postoperative recovery and was discharged in a stable condition. The culture growth showed the presence of Staphylococcus epidermidis, and appropriate antibiotics were administered, although blood cultures were negative. DISCUSSION The chronicity of the sinus and the presence of pulsatility led us to the suspicion of a deep-seated infection with probable communication to the cardiac vicinity (given the history). A simple debridement would have proved to be catastrophic. This led us to investigate the scenario and the underlying pathology, hence, a CT of the chest was performed. The treatment of left ventricular aneurysms necessitates the use of prosthetic material such as Teflon felt or bovine pericardium. Foreign material, such as Teflon felt, can be a nidus for indolent infection and abscess formation. It usually presents in 3 ways [1]: The most common of these being the cardiocutaneous fistulae (as in our case) presenting in the form of a subcutaneous lump or a draining abscess tracking up to the chest wall mostly in the lower part of the sternum [1]. A cardiobronchial fistula presenting as purulent haemoptysis with erosion into the surrounding lung parenchyma, especially in the left lower lobe [1]. Less commonly, systemic bacteraemia due to a pseudoaneurysm communicating with the ventricular cavity [1]. Recognizing the complication and initiating appropriate and aggressive surgical treatment is usually key to success. There is no uniform approach in treating this complication. Published experience is limited to anecdotal reports and variations in the surgical approach with regard to these patients [2]. All patients with suspected deep-seated infections must be evaluated with a CT scan [3] of the chest. It will throw further light on the location and size of the abscess and the relationship to the neighbouring structures, so that a proper surgical strategy can be planned [4]. In our case, left anterolateral thoracotomy gave a wide and direct access to the paracardiac abscess, and we believe that this approach is better than a redo sternotomy. It is always better to have the groin prepared for an emergency cardiopulmonary bypass [5]. We also believe that the abscess cavity should be deroofed, debrided well especially of the foreign material and the empty space to be filled with live tissue to avoid recurrence. Conflict of interest: none declared. REFERENCES 1 McHenry MC , Longworth DL , Rehm SJ , Keys TF , Moon HK , Cosgrove DM et al. Infections of the cardiac suture line after left ventricular surgery . Am J Med 1988 ; 85 : 292 – 300 . Google Scholar CrossRef Search ADS PubMed 2 Kejriwal NK , Paterson HS. Retrosternal fat pad for prevention of suppurative sternitis . Ann Thorac Surg 1997 ; 63 : 1484 – 5 . Google Scholar CrossRef Search ADS PubMed 3 Deuvaert FE , Wellens F , De Paepe J , Primo G. Cardio cutaneous fistula after left ventricular repair . J Cardiovasc Surg (Torino) 1984 ; 25 : 560 . Google Scholar PubMed 4 Engelman RM , Saxena A , Levitsky S. Delayed mediastinal infection after ventricular aneurysm resection . Ann Thorac Surg 1978 ; 25 : 470 . Google Scholar CrossRef Search ADS PubMed 5 Wellens F , Vanermen H. Treatment of the infected cardiac suture line . J Card Surg 1988 ; 3 : 109 – 18 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Infected Teflon felt strip-paracardiac abscess after Dor’s procedure

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Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
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1569-9285
D.O.I.
10.1093/icvts/ivy145
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Abstract

Abstract Foreign material used for reconstructing or suturing the cardiac chambers carries the risk of infection. When such a scenario is encountered, it is better to be aggressive in removing the infected source surgically, as conservative management will most often result in recurrence. Herein, we present an unusual case of infected prosthetic material after cardiac surgery that was managed surgically. This case reminds us of the surgical principle of eradicating the source of infection, which should be given priority. Teflon, Infection, Paracardiac, Abscess INTRODUCTION A 72-year-old hypertensive male presented with a chronic sinus and a granuloma in the epigastric region (Fig. 1) of 6 months. He had undergone coronary artery bypass grafting (CABG) surgery × 5 grafts + Dor’s procedure + left ventricle thrombectomy + infarctectomy 7 years ago through a median sternotomy in another institute. The patient’s medical history was suggestive of repeated surgical interventions for sternal instability. An incision and drainage for a swelling of acute onset in the epigastric region was performed 6 months earlier, which resulted in a chronic sinus. On examination, a pulsatile swelling (3 × 2 cm) was observed in the epigastric region surrounding the sinus (Video 1). His sternal wound was stable otherwise. His blood investigations were unremarkable, and there was no reported history of immunosuppression. A computed tomography (CT) scan of the chest showed a paracardiac abscess measuring 10 cm × 10 cm posterolateral to the left ventricle (Fig. 2) communicating to the epigastric region. It was decided to explore the abscess surgically with all precautions. Video 1 On table transmitted pulsations over the granuloma. Video 1 On table transmitted pulsations over the granuloma. Close Figure 1: View largeDownload slide Pulsatile granuloma with sternotomy scar. Figure 1: View largeDownload slide Pulsatile granuloma with sternotomy scar. Figure 2: View largeDownload slide A computed tomography scan showing a paracardiac abscess. Figure 2: View largeDownload slide A computed tomography scan showing a paracardiac abscess. The chest was entered through a left anterolateral thoracotomy with preparation of groin vessel cannulation for any eventuality. The left lung was released. Needle aspiration from the pericardial surface revealed purulent material. The sac was opened, and approximately 300 ml of pus was evacuated. The material was then sent for bacteriology. Abscess cavity loculations were opened, and sinus tract to the epigastric region was defined. Felt strips were found on the surface of heart and these felt strips were excised carefully in a piece meal manner. At every point, care was taken to ensure that no felt was ripped off, relying much on the intracavitary prosthetic material used in the primary procedure to afford safety from major bleeding. The tag was held by a gentle traction, allowing the heart beat to slowly dislodge the felt and the previous Prolene suture material. The abscess cavity was deroofed. The surrounding thymic and fatty tissues were mobilized as a pedicle and were utilized to fill the cavity. The foreign body granuloma site was excised, and the wound was closed in layers with a drain. The patient had an uneventful postoperative recovery and was discharged in a stable condition. The culture growth showed the presence of Staphylococcus epidermidis, and appropriate antibiotics were administered, although blood cultures were negative. DISCUSSION The chronicity of the sinus and the presence of pulsatility led us to the suspicion of a deep-seated infection with probable communication to the cardiac vicinity (given the history). A simple debridement would have proved to be catastrophic. This led us to investigate the scenario and the underlying pathology, hence, a CT of the chest was performed. The treatment of left ventricular aneurysms necessitates the use of prosthetic material such as Teflon felt or bovine pericardium. Foreign material, such as Teflon felt, can be a nidus for indolent infection and abscess formation. It usually presents in 3 ways [1]: The most common of these being the cardiocutaneous fistulae (as in our case) presenting in the form of a subcutaneous lump or a draining abscess tracking up to the chest wall mostly in the lower part of the sternum [1]. A cardiobronchial fistula presenting as purulent haemoptysis with erosion into the surrounding lung parenchyma, especially in the left lower lobe [1]. Less commonly, systemic bacteraemia due to a pseudoaneurysm communicating with the ventricular cavity [1]. Recognizing the complication and initiating appropriate and aggressive surgical treatment is usually key to success. There is no uniform approach in treating this complication. Published experience is limited to anecdotal reports and variations in the surgical approach with regard to these patients [2]. All patients with suspected deep-seated infections must be evaluated with a CT scan [3] of the chest. It will throw further light on the location and size of the abscess and the relationship to the neighbouring structures, so that a proper surgical strategy can be planned [4]. In our case, left anterolateral thoracotomy gave a wide and direct access to the paracardiac abscess, and we believe that this approach is better than a redo sternotomy. It is always better to have the groin prepared for an emergency cardiopulmonary bypass [5]. We also believe that the abscess cavity should be deroofed, debrided well especially of the foreign material and the empty space to be filled with live tissue to avoid recurrence. Conflict of interest: none declared. REFERENCES 1 McHenry MC , Longworth DL , Rehm SJ , Keys TF , Moon HK , Cosgrove DM et al. Infections of the cardiac suture line after left ventricular surgery . Am J Med 1988 ; 85 : 292 – 300 . Google Scholar CrossRef Search ADS PubMed 2 Kejriwal NK , Paterson HS. Retrosternal fat pad for prevention of suppurative sternitis . Ann Thorac Surg 1997 ; 63 : 1484 – 5 . Google Scholar CrossRef Search ADS PubMed 3 Deuvaert FE , Wellens F , De Paepe J , Primo G. Cardio cutaneous fistula after left ventricular repair . J Cardiovasc Surg (Torino) 1984 ; 25 : 560 . Google Scholar PubMed 4 Engelman RM , Saxena A , Levitsky S. Delayed mediastinal infection after ventricular aneurysm resection . Ann Thorac Surg 1978 ; 25 : 470 . Google Scholar CrossRef Search ADS PubMed 5 Wellens F , Vanermen H. Treatment of the infected cardiac suture line . J Card Surg 1988 ; 3 : 109 – 18 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Apr 26, 2018

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