Ann Thorac Surg 1998;66:564-566
© 1998 The Society of Thoracic Surgeons
Case Reports
Combined therapies for composite graft infection after Bentall’s procedure
Tamaki Takano, MDa,
Yukio Fukaya, MDa,
Hirofumi Nakano, MDa,
Hideo Kuroda, MDa,
Jun Amano, MDa
a Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
Accepted for publication March 2, 1998.
Address reprint requests to Dr Takano, Department of Surgery, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto 390, Japan
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Abstract
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We present a patient who suffered from composite graft infection and mediastinitis. After replacement of the infected composite graft, in addition to administration of antibiotics, continuous irrigation of the mediastinum with solutions containing povidone-iodine and cefazolin sodium and transposition of the greater omentum were performed. His postoperative course was uneventful. Combined therapies including mediastinal irrigation and omental transposition should be considered after an operation for composite graft infection complicated with mediastinitis.
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Introduction
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Composite graft infection is one of the fatal complications that can occur after Bentall’s procedure has been performed. As we have no single decisive therapy for this complication at present, combined therapies are necessary. The purpose of this report is to highlight the combined therapies for composite graft infection.
The patient was a 49-year-old man. At the age of 35 years, he underwent Bentall’s procedure with a composite graft (composed of a Björk-Shiley valve and a woven Dacron graft) for annuloaortic ectasia. At the age of 45 years, he underwent graft replacement of the aortic arch for Stanford A type acute aortic dissection. He was admitted to our hospital because of sudden fever and left hemiplegia. Cerebrospinal fluid examination and computed tomography of the head revealed a brain abscess in the right frontal lobe. Ultrasonic cardiography showed a vegetation on the prosthetic valve (Fig 1). Blood cultures showed colonies of Staphylococcus aureus. Benzylpenicillin potassium and gentamycin sulfate were given for 2 weeks intravenously and cefazolin sodium was given for 1 week intravenously. Computed tomography of the chest revealed an aortic root abscess 1 month after the onset of fever (Fig 2).
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Fig 1. Ultrasonic cardiography shows vegetation on the aortic curtain. (LA = left atrium, LV = left ventricle.)
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Fig 2. Chest computed tomogram (contrast enhancement) shows a low-density area around the ascending aorta and the aortic arch.
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The infected composite graft and the arch graft were replaced with a new composite graft after debridment of the surrounding infected tissues and part of the aortic annulus. The right and left coronary arteries were anastomosed to the Dacron graft with aortic buttons during the first Bentall’s operation. These were resected from the infected graft and reanastomosed to the new Dacron graft by Cabroll’s procedure. Continuous irrigation of the mediastinum with normal saline solution containing 0.1% povidone-iodine (250 mL/h for 4 hours) and 0.2% cefazolin sodium (500 mL/h for 1 hour) was started just after the operation. After irrigation for 3 days, the pedicle of the omentum was brought up to the mediastinum and wrapped around the new composite graft. Vancomycin hydrochloride and cefazolin sodium were given intravenously for 2 months after the operation. Then cefaclor was orally administered for 2 weeks.
The postoperative course was uneventful. The patient’s white blood cell count and C-reactive protein level gradually decreased and were within the normal range 3 months after the operation. The patient was discharged and returned to full-time work as a house painter. Neither clinical signs nor laboratory data of infection have been observed for 2 years of follow-up.
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Comment
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Cases of composite graft infection are occasionally reported [1, 2]. A composite graft infection often becomes a fatal complication after reconstruction of the aortic root. Composite graft infection leads to sepsis, systemic embolism, and heart failure as a result of prosthetic valve malfunction or disruption of the suture lines. Surgical treatment should be carried out immediately after the onset of composite graft infection [1, 3]. However, in this case, computed tomography of the brain revealed an abscess and 1 month later the operation was performed after the brain abscess was encapsulated.
Recommendations for the treatment of mediastinitis involving the vascular prosthesis include open exploration and debridment of infected tissue [1], continuous mediastinal irrigation with a solution containing povidone-iodine and antibiotics [4, 5], and transposition of muscle and the omentum [1, 2]. Composite graft infections were successfully treated without replacing the infected grafts by Séguin and Loisance [1]. On the other hand, Miller and Johnson [2] reported 2 cases in which they replaced the infected grafts. In our case, we elected to replace the infected composite graft because we observed both a brain abscess and vegetation on the prosthetic valve.
After the infected composite graft has been replaced, there remains a possibility of infection in the new composite graft with the same organism that infected the original composite graft. To prevent the new composite graft from becoming infected, we continuously irrigated the mediastinum with a solution containing povidone-iodine and normal saline solution containing cefazolin sodium. After irrigation for 3 days, the transposition of the greater omentum was performed. Glick and colleagues [5] reported toxicity of iodine caused by povidone-iodine irrigation. They stated that iodine is rapidly absorbed across the epithelium of the mediastinum during continuous mediastinal irrigation, which leads to high serum iodine levels. This could lead to metabolic acidosis, hyperosmolarity, renal failure, or hepatic failure. In this case, we used 0.1% povidone-iodine for mediastinal irrigation and did not observe hepatic failure, renal failure, or any other similar symptoms.
In case of composite graft infection, continuous mediastinal irrigation and omental transposition after replacement of the infected composite graft should be considered to prevent the new composite graft from becoming infected.
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References
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- Séguin J.R., Loisance D.Y. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest 1985;88:684-686.[Abstract/Free Full Text]
- Miller D.W., Jr, Johnson D.D. Omental pedicle graft in the management of infected ascending aortic prosthesis. Ann Thorac Surg 1987;44:614-617.[Abstract]
- Abe T., Tsukamoto M., Komatsu S. Surgical treatment of active infective endocarditis: early and late results of active native and prosthetic valve endocarditis. Jpn Circ J 1993;57:1080-1088.[Medline]
- Schumacker H.B., Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384-387.
- Glick P.L., Guglielmo B.J., Tranbaugh R.F., Turley K. Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann Thorac Surg 1985;39:478-480.[Abstract]
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Abstract
Introduction
