Ann Thorac Surg 2000;70:2140-2142
© 2000 The Society of Thoracic Surgeons
Case report
Removal of an infected ventricular septal defect patch after tetralogy repair
Joseph J. Amato, MDa,
William I. Douglas, MDa,
George J. Aboo Eid, MDa,
Frederick Lukash, MDa
a Department of Surgery, Long Island Jewish Medical Center, Schneider Children’s Hospital, New Hyde Park, New York, USA
Accepted for publication February 18, 2000.
Address reprint requests to Dr Amato, Rush Children’s Hospital, 1653 Congress Pkwy, Chicago, IL 60612
e-mail: joseph_amato{at}rsh.net
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Abstract
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An infected Dacron ventricular septal defect (VSD) patch was removed 15 years after repair of tetralogy of Fallot. Cardiopulmonary bypass was not utilized, and no significant hemorrhage was encountered. The patient recovered uneventfully and continues to do well 7 years after surgery without infection or residual VSD.
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Introduction
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The incidence of infection (endocarditis) of untreated ventricular septal defect (VSD) is approximately 0.2% per year [1]. The incidence of endocarditis subsequent to successful VSD closure is too uncommon to generate incidence data [2]. Scant reports are available in the literature of mediastino-cutaneous fistulas resulting from infected cardiac prostheses but these were from prostheses on the external surface of the heart (eg, right ventricular outflow tract patch [3–5]. No previous reports are available of a myocardial-cutaneous fistula resulting from an infected VSD patch.
A 21-year-old man was admitted with a draining sinus in the area of his lower sternum. The patient had previously undergone repair of tetralogy of Fallot at 3 years of age. The VSD was closed with a Dacron (C. R. Bard, Haverhill, PA) patch using nine interrupted, pledgeted, permanent braided sutures. The right ventricular outflow tract obstruction was relieved with muscle resection alone, and prosthetic material was not used. The patient had done well for 15 years when he returned with a painful indurated area over his sternum. The patient underwent local debridement and removal of a sternal wire followed by pectoralis flap reconstruction. The patient was left with a persistent draining sinus and 2 months later underwent further local debridement. This resulted in healing of the wound.
The patient did well for the next 2 years until he developed another draining sinus over the inferior portion of his sternum. The sinus tracked superiorly in the subcutaneous plane. Computerized tomography (CT) scan showed no substernal collections. Exploration by a plastic surgeon showed a sinus tract burrowing through the sternum 6 cm inferior to the sternomanubrial junction. Cardiac surgery consultation was then obtained. A fistulogram revealed contrast within the myocardium (Fig 1). The following day the patient was reexplored through a sternotomy. The sinus tracked through the sternum and into the interventricular septum. At the base of the sinus was the Dacron VSD patch and 6 pledgets and chronic granulation tissue. The patch and pledgets were removed from the myocardium using forceps (Fig 2). The granulation tissue was debrided with currettes. No significant hemorrhage was encountered, and cardiopulmonary bypass was not used. Intraoperative transesophageal echocardiography showed no residual VSD and no ventricular outflow tract obstruction. Intraoperative cultures grew Staphylococcus aureus. In retrospect, the patient believed he had seen two pledgets expectorated from his wound during the course of his illness.
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Fig 1. Fistulogram from the lateral projection showing dye traversing the sternum into the mediastinum.
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Postoperatively the patient was managed with Betadyne (Purdue Frederick Co, Norwalk, CT) and saline mediastinal irrigation for 10 days. On postoperative day 14, the chest tubes were removed, which resulted in hemorrhage into the right pleural space. The patient was returned to the operating room where 1,000 mL of blood clots was evacuated through a right thoracotomy. The etiology of the bleeding was unclear, and no active bleeding sites were found. The remainder of the patient’s hospital course was uneventful. The patient was treated with 6 weeks of intravenous cefazolin and gentamicin. The patient is now 2 years postoperative and is doing well without signs of recurrent infection, residual VSD, or ventricular outflow tract obstruction.
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Comment
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Few reports are available in the literature of chronic mediastino-cutaneous fistulas as a late complication of cardiac prosthetic material [3–5]. The few reports available describe these occurrences when the prosthetic material has been used on the outside of the heart, such as an infected right ventricular outflow tract patch or infected pledgets from an aortic anastomosis. There are no reports describing fistulas from an infected intracardiac prosthesis.
In our case the ventricular septal defect remained closed despite extrusion of the patch. Although we cannot definitely prove why there was no residual VSD, we presume that considerable fibrosis formed over the patch on both sides of the septum over the years. When the patch became infected and extruded, at least one plane of fibrosis remained intact to prevent reopening of the VSD.
Also of concern in our case is the issue of the infected sternal wire, which was the reason for the patient’s initial presentation. One could hypothesize whether the wire was the original site of infection and contaminated underneath. We do believe, however, that there is little reason to think that an infected wire could fistulize to the center of the heart. We hypothesize that an infected wire would fistulize to the skin before fistulizing to the center of the heart. On the other hand, there is good reason to think that a chronic infection in the center of the heart would fistulize out. Thus, we assume the infection started as a hematogenous spread to the VSD patch from a now unrecognized source.
Despite the unusual nature of the case, the standard surgical principles of treating chronic fistulous tracts (removal of foreign material and granulation tissue, copious irrigation, appropriate antibiotic therapy) resulted in a favorable outcome. It is our belief that a less aggressive procedure would not have resulted in eradication of the infection, and that aggressive removal of foreign, infected material should be performed if a similar situation arose in the future.
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References
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Tchervenkov C.I., Shum-Tim D. Ventricular septal defects. In: Baue A.E., Geha A.S., Hammond G.L., Laks H., Naunheim K.S., eds. Glenn’s thoracic and cardiovascular surgery. Baltimore: Appleton & Lange, 1996:1132.
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In: Kirklin J.W., Barratt-Boyes B.G., eds. Cardiac surgery. Edinburgh: Churchill Livingstone, 1993.
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Yener A., Ayrancioglu K., Aslamaci S., Ekici E., Ikizler C. An unusual late complication following surgical repair of tetralogy of Fallot. J Cardiovasc Surg 1990;31:587-588.[Medline]
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Conn K.S., Dunning J.J., Pillai R. Extrusion of Teflon aortic pledgets from a sternal wound six years after cardiac surgery. Eur J Cardiothorac Surg 1997;12:150-151.[Abstract]
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Carrel T., Winklehner H., Pasic M., Turina M. Spontaneous expectoration of a modified Blalock-Taussig Gore-Tex shunt 9 years after implantation. N Engl J Med 1993;329:1899.[Free Full Text]
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Abstract
Introduction
