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Successful Treatment of an Infected Right Ventricular to Pulmonary Artery Conduit
CASE REPORTS
Successful Treatment of an Infected Right Ventricular to Pulmonary Artery Conduit Jack G. Copeland, M.D., Clifford M. Morgan, M.D., David J. Sahn, M.D., Hugh D. Allen, M.D., and Stanley J. Goldberg, M.D. ABSTRACT This case report discusses the successful surgical management of a Staphylococcus aureus infection in and around a Hancock porcine valved xenograft conduit. After 14 days of persistent septicemia on antibiotics, the patient underwent replacement of the conduit. He is currently doing well, without antibiotics.
1978, for further evaluation of known tetralogy of Fallot. He had undergone pulmonary valvulotomy at the age of 7 years. On admission he was noted to be acyanotic, with a blood pressure of 112170. Cardiac examination revealed a grade 416 systolic ejection murmur with a grade 314 diastolic murmur and a diffuse thrill over the precordium. Cardiac catheterization The use of synthetic material in cardiac and (Table) demonstrated a 50 mm Hg gradient vascular operations has increased dramatically across the pulmonary valve area, an oxygen over the past two decades. Grafts composed of saturation step up in the right ventricle, a synthetic material are routinely utilized in re- pulmonic-to-systemic flow ratio of 1.3 : 1, conconstruction of aortic, ileal, femoral, and pop- siderable infundibular muscle bands, a large liteal disease. In cardiac operations, prosthetic right ventricular body, and aneurysmal dilatation valves are widely accepted, with porcine of the pulmonary artery distal to the pulmonic heterografts becoming increasingly popular. valve annulus, which was markedly stenotic. However, the use of graft material in the repair The patient was judged to be a candidate for of complex congenital heart malformations in- total repair. Severe stenosis of the pulmonary volving reconstruction of the right ventricular annulus and proximal main pulmonary artery outflow tract remains highly controversial. were major factors that determined the use of a Reluctance to use graft material is partially right ventricular to pulmonary artery conflurelated to the continued risk of infection, which ence valved conduit. Muscle bundles were exin prosthetic valves has been reported from less cised through a right ventriculotomy using a than 1to 4% [l-41. Infection in right ventricular longitudinal incision, and a woven Teflon patch outflow tract patches and conduits has been re- was utilized to repair the ventricular septa1 deported only rarely in the literature [5-81, and fect. A 25 mm porcine xenograft was then these incidents are frequently associated with a placed from the ventriculotomy to the confluhigh mortality rate. This report discusses the ence of the pulmonary arteries in an end-to-end successful management of an infection with fashion. The heart defibrillated spontaneously. abscess in a Hancock porcine xenograft conduit Upon completion of the operation, a 10 mm originally placed for correction of tetralogy of gradient across the conduit was recorded. Fallot. Postoperatively the patient had temperatures as high as 38°C for nine days; multiple blood A 13-year-old boy was admitted to the Univer- cultures were negative. A pleural effusion was sity of Arizona Health Sciences Center in July, drained on the tenth postoperative day. No organisms were found in the thoracentesis fluid, From the Department of Surgery, Section of Cardiovascular and Thoracic Surgery, and the Department of Pediatrics, and the patient was discharged afebrile on the Section of Cardiology, University of Arizona Health Sci- twelfth postoperative day. ences Center, Tucson, AZ. He did well until June, 1979, nearly one year Accepted for publication Jan 25, 1982. later. At that time he was admitted to the Fort Address reprint requests to Dr. Copeland, Surgery Department, Room 4402, University of Arizona Health Sciences Worth Children's Hospital with a temperature of 105"F, lethargy, and extensive pyoderma of Center, 1501 N Campbell Ave, Tucson, AZ 85724. 308
309 Case Report: Copeland et al: Infected Right Ventricular to Pulmonary Artery Conduit
Summary of Cardiac Catheterization Pressures Pressure (mm Hg) Date
RA
RV
PA
RPA
LA
LV
Aortic
CO (Llmin)
7/78 6/79 10179 7/80
9 10 5
110110 96/14 85112 70110
30110
... ...
...
120114
120180
5.44
... ... ...
... ... ...
... ... ...
... ...
9
... 60115a
...
2018 25/15
8.08
aDistal to conduit valve.
RA = right atrial; RV = right ventricular; PA = pulmonary artery; RPA = right pulmonary artery; LA = left atrial; LV = left ventricular; CO = cardiac output.
the extremities, apparently due to secondarily infected insect bites, acquired several days before, on both thighs. White blood cell count on admission was 16,000 with a left shift, and chest roentgenography demonstrated borderline cardiomegaly and an enlargement in the region of the pulmonary outflow tract. The patient was given chloramphenicol and kanamycin. At 36 hours, the patient's blood culture grew Staphylococcus aureus, and he developed a petechial rash with subsequent desquamation of the skin on the hands and feet. The antibiotics were changed to methicillin and gentamicin. Serial chest roentgenograms showed an enlarging mass in the left superior mediastinum adjacent to the prosthetic valve ring. A coned-down view of the abscess can be seen in Figure 1. Cineangiography on the eighth day (Table) demonstrated dilatation of the right ventricle with poor contractility, 1 to 2+ tricuspid regurgitation, marked thickening of the porcine xenograft, and a nonpacified mass lesion adjacent to the conduit. On the fourteenth day the patient, still febrile (up to 105"F), was transferred to the University of Arizona Health Sciences Center. A twodimensional echocardiogram done at admission showed poorly moving prosthetic valve leaflets, evidence of right ventricular hypertension, and a probable abscess surrounding the conduit. The patient was taken to the operating room where an abscess cavity containing 50 to 100 ml of frankly purulent material was drained. The walls of the abscess cavity as well as the conduit were excised. A similar 25 mm Dacron conduit with a porcine valve was in-
Fig I . Coned-down view of periconduit abscess.
serted, and the chest was copiously irrigated with 10% povidone-iodine and cephapirin solutions. Pathological examination of the valve showed bacterial excrescences on its surface (Fig 2). Cultures from this valve and abscess grew S. uureus. The patient was maintained on methicillin and gentamicin until the fourth postoperative day, at which time the antibiotics were changed to 100 mg per kilogram per day of intravenous cephalothin after an episode of hematuria and mild elevation of creatinine. He had no fever by the tenth day, and his white blood count was normal on the sixteenth day.
310 The Annals of Thoracic Surgery Vol 35 No 3 March 1983
Fig 2 . The porcine valve.
Blood cultures were negative. On postoperative day 29, antibiotics were changed to 750 mg of dicloxacillin administered orally four times a day, and the patient was discharged two days later on dicloxacillin. Four months after the operation, cardiac catheterization showed right ventricular dysfunction, a 40 mm Hg gradient at the distal anastomosis, and a 25 mm Hg gradient at the valve (see Table). Because of these findings and the patient’s complaint of mild fatigue with exercise, he was returned to the operating room in June, 1980, two years after his initial procedure and one year after removal of the infected conduit (Fig 3). The conduit was replaced with a 26 mm woven Dacron tube graft, and the right pulmonary artery was enlarged using a GoreTex* patch graft. Cultures of the area of previous infection and of the conduit were negative, and there was no gross evidence of infection. Closing pressures showed a gradient of 30 to 35 mm Hg across the conduit. Postoperatively the patient was continued on digoxin and dicloxacillin. Cardiac catheterization on the twelfth postoperative day showed small pulmonary arteries with a 50 mm Hg gradient from the conduit to the right and a 40 mm Hg gradient to the left, as well as wide-open regurgitation through the conduit (see Table). The
*W.L. Gore & Associates, Inc., Elkton, MD 21921.
Fig 3 . Chest roentgenogram before removal of the second conduit.
patient was discharged three days later on dicloxacillin and digoxin. On February 3,1981, an echocardiogram with a Doppler flow study demonstrated wide-open pulmonary regurgitation. Clinically, the patient had good activity tolerance. His antibiotics were discontinued, and he remains well, with no evidence of recurring infection.
Comment Among the risks inherent in the use of synthetic valves and graft material, infection may be the most serious. The case presented is important because it demonstrates that an infection of a porcine xenograft with periconduit abscess can be successfully controlled. Prosthetic valve infections have generally been grouped into those occurring within 4 to 8 weeks postoperatively (early) and those appearing later [9-121. Those appearing early are thought to be caused by bacteria introduced at the time of operation. We report an example of a late prosthetic valve infection, undoubtedly secondary to a bacteremia associated with pyoderma, a common cause 191. Overall, the late infections tend to have a lower associated
311 Case Report: Copeland et al: Infected Right Ventricular to Pulmonary Artery Conduit
mortality rate-between 20 and 36%compared with the 70 to 87% rate for early infections [I, 9, 101. The concomitant existence of an abscess in a late infection would raise the risk considerably. The incidence of infection in glutaraldehyde-treated porcine valves has been reported to be between 0.6 and 3.7% [13, 141. A review by Ferrans and associates found 47 cases reported in the literature, with an overall mortality rate of 40%. Distinct differences in infection in porcine valves versus rigid-frame prosthetic valves were described, including the location of the infection, the area of destruction, and the existence of abscesses involving the valve ring. The incidence of abscesses of the valve ring in that group was 6% and was associated with a 66% mortality rate due to dysfunction [12, 161. Management of infected valve prostheses and graft material has been a long-standing problem. Late valve infections have a lower mortality rate and better response to medical management when compared to early infections [l, 16, 171. Operation is indicated if the patient fails to respond to antibiotic treatment or has recurrent embolic episodes, or if congestive failure that is refractory to medical management appears [l,7,18,19]. The aim of operation is to remove the source of continued sepsis and to replace the hemodynamically ineffective valve. Operative mortality associated with replacement of infected native valves is 25 to 38% 118-201; in infection of porcine valves, this rate rises to 80% [15, 16, 21, 221. The incidence of infection in plastic graft material used in peripheral arterial reconstruction procedures ranges from 1.5 to 6% [23, 241. For these infections there is an associated 37% mortality rate and a 37% rate of extremity loss 1231. One of the most common initial symptoms of infection is an enlarging infected aneurysm secondary to disruption of the suture line by bacteria [23, 25, 261. Treatment of the infection is by removal of the infected material and amputation or extraanatomical reconstruction [23]. The management of an infected valved conduit presents an even greater surgical challenge, in that both the valve and conduit must be corrected. There are few accounts of suc-
cessful treatments of such infections. Ciaravella and co-workers [5] reported 6 cases of mediastinitis that involved conduits (aortic homografts and Hancock valves) and were associated with a 100% mortality rate. Norwood and colleagues [6] described 3 patients with early conduit infections, which responded well to antibiotics. In the same study, 2 late infections in allografts responded to antibiotics, but 2 in Hancock conduits resulted in death, 1 after replacement. Thompson and associates [71 described the survival of 1 patient after excision of an infected aortic homograft and replacement with a Hancock prosthesis using high-dose antibiotics concurrently. In another case report, by Moseley and co-workers [8], an early infection of a Hancock conduit was successfully treated by use of antibiotics and continuous irrigation of the chest with povidone-iodine. In this patient, the prosthesis was not excised. We would advocate excision of the prosthesis and the surrounding infected material. The case we report is one of the few instances of successful surgical management of infection in a Hancock porcine xenograft conduit that was resistant to antibiotic therapy. Debridement of the infected material combined with antibiotic therapy proved effective in the management of this often lethal complication.
References 1. Slaughter L, Morris JE, Starr A: Prosthetic valve endocarditis: a 12-year review. Circulation 47: 1319, 1973 2. Weinstein L, Rubin RH: Infective endocarditis1973. Prog Cardiovasc Dis 16:239, 1973 3. Masor H, Johnson WD: Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 80:31, 1980 4. Watana KC: Prosthetic valve infective endocarditis. Prog Cardiovasc Dis 22:181, 1979 5. Ciaravella Jh4,McGoon DC, Danielson GK, et al: Experience with the external conduit. J Thorac Cardiovasc Surg 78:920, 1979 6. Norwood WI,Freed MD, Rocchini AP, et al: Experience with valved conduits for repair of congenital cardiac lesions. Ann Thorac Surg 24223, 1977 7. Thompson J, Dirksen T, Nube M, et al: Prosthesis endocarditis: treatment of a case occumng five years after a Rastelli-Rossoperation. J Thorac Cardiovasc Surg 72:28, 1976 8. Moseley PW, Ochsner JL, Mills NL, et al: Management of an infected Hancock prosthesis after
312 The Annals of Thoracic Surgery Vol 35 N o 3 March 1983
repair of truncus arteriosus. J Thorac Cardiovasc Surg 73:306, 1977 9. Shafer RB, Hall WH: Bacterial endocarditis following open heart surgery. Am J Cardiol25:602, 1970 10. Block PC, DeSanetis RW, Weinberg AW, et al: Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 6090, 1970 11. Yeh TJ, Anabtawi IN, Cornett VE, et al: Bacterial endocarditis following open heart surgery. Ann Thorac Surg 3:29, 1967 12. Ferrans VJ, Boyce SW, Billingham ME, et al: Infection of glutaraldehyde-preserved porcine valve heterografts. Am J Cardiol43:1123, 1979 13. Hatcher C: Discussion of Magilligan et a1 [16]. Ann Thorac Surg 24:517, 1977 14. McIntosh CL, Michaelis LL, Morrow AG, et al: Atrioventricular valve replacement with the Hancock porcine xenograft: a five-year clinical experience. Surg 78:768, 1975 15. Oyer PE, Stinson EB, Griepp RB, et al: Valve replacement with the Starr-Edwards and Hancock prosthesis: comparative analysis of late morbidity and mortality. Ann Surg 186:301, 1977 16. Magilligan DJ, Quinn EL, Davilla JC: Bacteremia, endocarditis, and the Hancock valve. Ann Thorac Surg 24:508, 1977 17. Petheram IS, Boyce JM: Prosthetic valve endocarditis: a review of 24 cases. Thorax 32:478, 1977
18. Black S, ORourke RA, Karliner JS: Role of
19.
20.
21.
22. 23. 24.
25. 26.
surgery in the treatment of primary infectious endocarditis. Am J Med 56:357, 1974 Parroff JC, Hill JD, Kerth WJ, et al: The surgical management of bacterial endocarditis: a review. Ann Surg 183:289, 1976 Jung JY, Saab SB, Almond CH: The case for early surgical treatment of left-sided primary infective endocarditis: a collective review. J Thorac Cardiovasc Surg 70:509, 1975 Carpentier A, Deloche A, Relland J, et al: Sixyear follow-up of glutaraldehyde-preserved heterograft with particular reference to the treatment of congenital valve malformities. J Thorac Cardiovasc Surg 68:771, 1974 Stinson EB, Griepp RB, Oyer PE, et al: Longterm experience with porcine aortic valve xenografts. J Thorac Cardiovasc Surg 7354, 1977 Goldstone J, Moore WS: Infection in vascular prostheses. Am J Surg 128:225, 1974 Goldstone J, Effeney DJ: Prevention of arterial graft infections. In Bemhard UM, Towne J, Grune G: Complications of Vascular Surgery. New York, Stratton, 1980, pp 491-502 Eckman CA, Scott HW: Influence of experimental staphylococcus infections on arterial anastomoses and grafts. Bull SOCInt Chir 19:133,1960 Schramel RJ, Guch 0: Effects of infection and exposure on synthetic arterial prostheses. Arch Surg 78:101, 1959
Successful Treatment of an Infected Right Ventricular to Pulmonary Artery Conduit Jack G. Copeland, M.D., Clifford M. Morgan, M.D., David J. Sahn, M.D., Hugh D. Allen, M.D., and Stanley J. Goldberg, M.D. ABSTRACT This case report discusses the successful surgical management of a Staphylococcus aureus infection in and around a Hancock porcine valved xenograft conduit. After 14 days of persistent septicemia on antibiotics, the patient underwent replacement of the conduit. He is currently doing well, without antibiotics.
1978, for further evaluation of known tetralogy of Fallot. He had undergone pulmonary valvulotomy at the age of 7 years. On admission he was noted to be acyanotic, with a blood pressure of 112170. Cardiac examination revealed a grade 416 systolic ejection murmur with a grade 314 diastolic murmur and a diffuse thrill over the precordium. Cardiac catheterization The use of synthetic material in cardiac and (Table) demonstrated a 50 mm Hg gradient vascular operations has increased dramatically across the pulmonary valve area, an oxygen over the past two decades. Grafts composed of saturation step up in the right ventricle, a synthetic material are routinely utilized in re- pulmonic-to-systemic flow ratio of 1.3 : 1, conconstruction of aortic, ileal, femoral, and pop- siderable infundibular muscle bands, a large liteal disease. In cardiac operations, prosthetic right ventricular body, and aneurysmal dilatation valves are widely accepted, with porcine of the pulmonary artery distal to the pulmonic heterografts becoming increasingly popular. valve annulus, which was markedly stenotic. However, the use of graft material in the repair The patient was judged to be a candidate for of complex congenital heart malformations in- total repair. Severe stenosis of the pulmonary volving reconstruction of the right ventricular annulus and proximal main pulmonary artery outflow tract remains highly controversial. were major factors that determined the use of a Reluctance to use graft material is partially right ventricular to pulmonary artery conflurelated to the continued risk of infection, which ence valved conduit. Muscle bundles were exin prosthetic valves has been reported from less cised through a right ventriculotomy using a than 1to 4% [l-41. Infection in right ventricular longitudinal incision, and a woven Teflon patch outflow tract patches and conduits has been re- was utilized to repair the ventricular septa1 deported only rarely in the literature [5-81, and fect. A 25 mm porcine xenograft was then these incidents are frequently associated with a placed from the ventriculotomy to the confluhigh mortality rate. This report discusses the ence of the pulmonary arteries in an end-to-end successful management of an infection with fashion. The heart defibrillated spontaneously. abscess in a Hancock porcine xenograft conduit Upon completion of the operation, a 10 mm originally placed for correction of tetralogy of gradient across the conduit was recorded. Fallot. Postoperatively the patient had temperatures as high as 38°C for nine days; multiple blood A 13-year-old boy was admitted to the Univer- cultures were negative. A pleural effusion was sity of Arizona Health Sciences Center in July, drained on the tenth postoperative day. No organisms were found in the thoracentesis fluid, From the Department of Surgery, Section of Cardiovascular and Thoracic Surgery, and the Department of Pediatrics, and the patient was discharged afebrile on the Section of Cardiology, University of Arizona Health Sci- twelfth postoperative day. ences Center, Tucson, AZ. He did well until June, 1979, nearly one year Accepted for publication Jan 25, 1982. later. At that time he was admitted to the Fort Address reprint requests to Dr. Copeland, Surgery Department, Room 4402, University of Arizona Health Sciences Worth Children's Hospital with a temperature of 105"F, lethargy, and extensive pyoderma of Center, 1501 N Campbell Ave, Tucson, AZ 85724. 308
309 Case Report: Copeland et al: Infected Right Ventricular to Pulmonary Artery Conduit
Summary of Cardiac Catheterization Pressures Pressure (mm Hg) Date
RA
RV
PA
RPA
LA
LV
Aortic
CO (Llmin)
7/78 6/79 10179 7/80
9 10 5
110110 96/14 85112 70110
30110
... ...
...
120114
120180
5.44
... ... ...
... ... ...
... ... ...
... ...
9
... 60115a
...
2018 25/15
8.08
aDistal to conduit valve.
RA = right atrial; RV = right ventricular; PA = pulmonary artery; RPA = right pulmonary artery; LA = left atrial; LV = left ventricular; CO = cardiac output.
the extremities, apparently due to secondarily infected insect bites, acquired several days before, on both thighs. White blood cell count on admission was 16,000 with a left shift, and chest roentgenography demonstrated borderline cardiomegaly and an enlargement in the region of the pulmonary outflow tract. The patient was given chloramphenicol and kanamycin. At 36 hours, the patient's blood culture grew Staphylococcus aureus, and he developed a petechial rash with subsequent desquamation of the skin on the hands and feet. The antibiotics were changed to methicillin and gentamicin. Serial chest roentgenograms showed an enlarging mass in the left superior mediastinum adjacent to the prosthetic valve ring. A coned-down view of the abscess can be seen in Figure 1. Cineangiography on the eighth day (Table) demonstrated dilatation of the right ventricle with poor contractility, 1 to 2+ tricuspid regurgitation, marked thickening of the porcine xenograft, and a nonpacified mass lesion adjacent to the conduit. On the fourteenth day the patient, still febrile (up to 105"F), was transferred to the University of Arizona Health Sciences Center. A twodimensional echocardiogram done at admission showed poorly moving prosthetic valve leaflets, evidence of right ventricular hypertension, and a probable abscess surrounding the conduit. The patient was taken to the operating room where an abscess cavity containing 50 to 100 ml of frankly purulent material was drained. The walls of the abscess cavity as well as the conduit were excised. A similar 25 mm Dacron conduit with a porcine valve was in-
Fig I . Coned-down view of periconduit abscess.
serted, and the chest was copiously irrigated with 10% povidone-iodine and cephapirin solutions. Pathological examination of the valve showed bacterial excrescences on its surface (Fig 2). Cultures from this valve and abscess grew S. uureus. The patient was maintained on methicillin and gentamicin until the fourth postoperative day, at which time the antibiotics were changed to 100 mg per kilogram per day of intravenous cephalothin after an episode of hematuria and mild elevation of creatinine. He had no fever by the tenth day, and his white blood count was normal on the sixteenth day.
310 The Annals of Thoracic Surgery Vol 35 No 3 March 1983
Fig 2 . The porcine valve.
Blood cultures were negative. On postoperative day 29, antibiotics were changed to 750 mg of dicloxacillin administered orally four times a day, and the patient was discharged two days later on dicloxacillin. Four months after the operation, cardiac catheterization showed right ventricular dysfunction, a 40 mm Hg gradient at the distal anastomosis, and a 25 mm Hg gradient at the valve (see Table). Because of these findings and the patient’s complaint of mild fatigue with exercise, he was returned to the operating room in June, 1980, two years after his initial procedure and one year after removal of the infected conduit (Fig 3). The conduit was replaced with a 26 mm woven Dacron tube graft, and the right pulmonary artery was enlarged using a GoreTex* patch graft. Cultures of the area of previous infection and of the conduit were negative, and there was no gross evidence of infection. Closing pressures showed a gradient of 30 to 35 mm Hg across the conduit. Postoperatively the patient was continued on digoxin and dicloxacillin. Cardiac catheterization on the twelfth postoperative day showed small pulmonary arteries with a 50 mm Hg gradient from the conduit to the right and a 40 mm Hg gradient to the left, as well as wide-open regurgitation through the conduit (see Table). The
*W.L. Gore & Associates, Inc., Elkton, MD 21921.
Fig 3 . Chest roentgenogram before removal of the second conduit.
patient was discharged three days later on dicloxacillin and digoxin. On February 3,1981, an echocardiogram with a Doppler flow study demonstrated wide-open pulmonary regurgitation. Clinically, the patient had good activity tolerance. His antibiotics were discontinued, and he remains well, with no evidence of recurring infection.
Comment Among the risks inherent in the use of synthetic valves and graft material, infection may be the most serious. The case presented is important because it demonstrates that an infection of a porcine xenograft with periconduit abscess can be successfully controlled. Prosthetic valve infections have generally been grouped into those occurring within 4 to 8 weeks postoperatively (early) and those appearing later [9-121. Those appearing early are thought to be caused by bacteria introduced at the time of operation. We report an example of a late prosthetic valve infection, undoubtedly secondary to a bacteremia associated with pyoderma, a common cause 191. Overall, the late infections tend to have a lower associated
311 Case Report: Copeland et al: Infected Right Ventricular to Pulmonary Artery Conduit
mortality rate-between 20 and 36%compared with the 70 to 87% rate for early infections [I, 9, 101. The concomitant existence of an abscess in a late infection would raise the risk considerably. The incidence of infection in glutaraldehyde-treated porcine valves has been reported to be between 0.6 and 3.7% [13, 141. A review by Ferrans and associates found 47 cases reported in the literature, with an overall mortality rate of 40%. Distinct differences in infection in porcine valves versus rigid-frame prosthetic valves were described, including the location of the infection, the area of destruction, and the existence of abscesses involving the valve ring. The incidence of abscesses of the valve ring in that group was 6% and was associated with a 66% mortality rate due to dysfunction [12, 161. Management of infected valve prostheses and graft material has been a long-standing problem. Late valve infections have a lower mortality rate and better response to medical management when compared to early infections [l, 16, 171. Operation is indicated if the patient fails to respond to antibiotic treatment or has recurrent embolic episodes, or if congestive failure that is refractory to medical management appears [l,7,18,19]. The aim of operation is to remove the source of continued sepsis and to replace the hemodynamically ineffective valve. Operative mortality associated with replacement of infected native valves is 25 to 38% 118-201; in infection of porcine valves, this rate rises to 80% [15, 16, 21, 221. The incidence of infection in plastic graft material used in peripheral arterial reconstruction procedures ranges from 1.5 to 6% [23, 241. For these infections there is an associated 37% mortality rate and a 37% rate of extremity loss 1231. One of the most common initial symptoms of infection is an enlarging infected aneurysm secondary to disruption of the suture line by bacteria [23, 25, 261. Treatment of the infection is by removal of the infected material and amputation or extraanatomical reconstruction [23]. The management of an infected valved conduit presents an even greater surgical challenge, in that both the valve and conduit must be corrected. There are few accounts of suc-
cessful treatments of such infections. Ciaravella and co-workers [5] reported 6 cases of mediastinitis that involved conduits (aortic homografts and Hancock valves) and were associated with a 100% mortality rate. Norwood and colleagues [6] described 3 patients with early conduit infections, which responded well to antibiotics. In the same study, 2 late infections in allografts responded to antibiotics, but 2 in Hancock conduits resulted in death, 1 after replacement. Thompson and associates [71 described the survival of 1 patient after excision of an infected aortic homograft and replacement with a Hancock prosthesis using high-dose antibiotics concurrently. In another case report, by Moseley and co-workers [8], an early infection of a Hancock conduit was successfully treated by use of antibiotics and continuous irrigation of the chest with povidone-iodine. In this patient, the prosthesis was not excised. We would advocate excision of the prosthesis and the surrounding infected material. The case we report is one of the few instances of successful surgical management of infection in a Hancock porcine xenograft conduit that was resistant to antibiotic therapy. Debridement of the infected material combined with antibiotic therapy proved effective in the management of this often lethal complication.
References 1. Slaughter L, Morris JE, Starr A: Prosthetic valve endocarditis: a 12-year review. Circulation 47: 1319, 1973 2. Weinstein L, Rubin RH: Infective endocarditis1973. Prog Cardiovasc Dis 16:239, 1973 3. Masor H, Johnson WD: Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 80:31, 1980 4. Watana KC: Prosthetic valve infective endocarditis. Prog Cardiovasc Dis 22:181, 1979 5. Ciaravella Jh4,McGoon DC, Danielson GK, et al: Experience with the external conduit. J Thorac Cardiovasc Surg 78:920, 1979 6. Norwood WI,Freed MD, Rocchini AP, et al: Experience with valved conduits for repair of congenital cardiac lesions. Ann Thorac Surg 24223, 1977 7. Thompson J, Dirksen T, Nube M, et al: Prosthesis endocarditis: treatment of a case occumng five years after a Rastelli-Rossoperation. J Thorac Cardiovasc Surg 72:28, 1976 8. Moseley PW, Ochsner JL, Mills NL, et al: Management of an infected Hancock prosthesis after
312 The Annals of Thoracic Surgery Vol 35 N o 3 March 1983
repair of truncus arteriosus. J Thorac Cardiovasc Surg 73:306, 1977 9. Shafer RB, Hall WH: Bacterial endocarditis following open heart surgery. Am J Cardiol25:602, 1970 10. Block PC, DeSanetis RW, Weinberg AW, et al: Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 6090, 1970 11. Yeh TJ, Anabtawi IN, Cornett VE, et al: Bacterial endocarditis following open heart surgery. Ann Thorac Surg 3:29, 1967 12. Ferrans VJ, Boyce SW, Billingham ME, et al: Infection of glutaraldehyde-preserved porcine valve heterografts. Am J Cardiol43:1123, 1979 13. Hatcher C: Discussion of Magilligan et a1 [16]. Ann Thorac Surg 24:517, 1977 14. McIntosh CL, Michaelis LL, Morrow AG, et al: Atrioventricular valve replacement with the Hancock porcine xenograft: a five-year clinical experience. Surg 78:768, 1975 15. Oyer PE, Stinson EB, Griepp RB, et al: Valve replacement with the Starr-Edwards and Hancock prosthesis: comparative analysis of late morbidity and mortality. Ann Surg 186:301, 1977 16. Magilligan DJ, Quinn EL, Davilla JC: Bacteremia, endocarditis, and the Hancock valve. Ann Thorac Surg 24:508, 1977 17. Petheram IS, Boyce JM: Prosthetic valve endocarditis: a review of 24 cases. Thorax 32:478, 1977
18. Black S, ORourke RA, Karliner JS: Role of
19.
20.
21.
22. 23. 24.
25. 26.
surgery in the treatment of primary infectious endocarditis. Am J Med 56:357, 1974 Parroff JC, Hill JD, Kerth WJ, et al: The surgical management of bacterial endocarditis: a review. Ann Surg 183:289, 1976 Jung JY, Saab SB, Almond CH: The case for early surgical treatment of left-sided primary infective endocarditis: a collective review. J Thorac Cardiovasc Surg 70:509, 1975 Carpentier A, Deloche A, Relland J, et al: Sixyear follow-up of glutaraldehyde-preserved heterograft with particular reference to the treatment of congenital valve malformities. J Thorac Cardiovasc Surg 68:771, 1974 Stinson EB, Griepp RB, Oyer PE, et al: Longterm experience with porcine aortic valve xenografts. J Thorac Cardiovasc Surg 7354, 1977 Goldstone J, Moore WS: Infection in vascular prostheses. Am J Surg 128:225, 1974 Goldstone J, Effeney DJ: Prevention of arterial graft infections. In Bemhard UM, Towne J, Grune G: Complications of Vascular Surgery. New York, Stratton, 1980, pp 491-502 Eckman CA, Scott HW: Influence of experimental staphylococcus infections on arterial anastomoses and grafts. Bull SOCInt Chir 19:133,1960 Schramel RJ, Guch 0: Effects of infection and exposure on synthetic arterial prostheses. Arch Surg 78:101, 1959