Deep sternal wire infection resulting in severe pulmonary valve endocarditis

Right Ventricular Outflow Tract Obstruction in Adults: A Systematic Review and Meta-analysis

Background

Right ventricular outflow tract obstruction (RVOTO) is a cause of hemodynamic instability that can occur in several situations, including cardiac surgery, lung transplantation, and thoracic surgery, and in critically ill patients. The timely diagnosis of RVOTO is important because it requires specific considerations, including the adverse effects of positive inotropes, and depending on the etiology, the requirement for urgent surgical intervention.

Methods

The objective of this systematic review and meta-analysis was to determine the prevalence of RVOTO in adult patients, and the distribution of all reported cases by etiology.

Results

Of 233 available reports, there were 229 case reports or series, and 4 retrospective cohort studies, with one study also reporting a prospective cohort. Of 291 reported cases of RVOTO, 61 (21%) were congenital, 56 (19%) were iatrogenic, and 174 (60%) were neither congenital nor iatrogenic (including intracardiac tumour). The mechanism of RVOTO was an intrinsic obstruction in 169 cases (58%), and an extrinsic obstruction in 122 cases (42%). A mechanical obstruction causing RVOTO was present in 262 cases (90%), and 29 cases of dynamic RVOTO (10%) were reported. In the 5 included cohorts, with a total of 1122 patients, the overall prevalence was estimated to be 4.0% (1%-9%).

Conclusions

RVOTO, though rare, remains clinically important, and therefore, multicentre studies are warranted to better understand the prevalence, causes, and consequences of RVOTO.

Dermatologic surgery on the chest wall in patients with a cardiac surgery history: a review of material that may be encountered intraoperatively, including potential complications and suggestions for proceeding safely

Background

Thoracic surgical procedures and the use of cardiac devices such as pacemakers are becoming increasingly prevalent in the population. As such, dermatologists may have a greater likelihood of encountering previously implanted or abandoned surgical material in the course of dermatologic surgery on the chest wall. A basic understanding of the wire types and the tunneling paths utilized in such procedures is important in accurately anticipating the presence of these wires to effectively manage any chance encounters.

Objective

We present a review on temporary epicardial pacing wires, temporary transvenous pacing wires, pacemaker leads, and surgical steel sutures in the context of dermatologic surgery.

Methods

A literature review was performed on frequently used wire material in patients with a history of cardiac surgery as well as related dermatologic complications from these materials.

Results & Conclusion

Dermatologic surgeons should particularly be aware that temporary epicardial pacing wires and pacemaker leads are not uncommonly abandoned in the chest wall of many patients. All patients with a cardiac surgery history should be questioned about possible retained wires. If wire material is encountered intraoperatively, immediately stop the procedure and do not attempt further manipulation of the wire until suggested steps are taken to ascertain the wire type.

Isolated Pulmonary Valve Endocarditis

Endocarditis of only the pulmonary valve is a very rare finding and is often missed during echocardiographic evaluation due to limited views of the pulmonary valve and a low index of suspicion. We report 2 cases of pulmonary valve endocarditis (PVE), highlighting the importance of echocardiography in the assessment of the infected pulmonary valve. In addition, we review the published case reports of isolated PVE from 1979 to 2013 in order to study the role of echocardiography in the diagnosis of pulmonary valve masses.

Case report of a rare complication of open-heart surgery masquerading as a gunshot wound: an autopsy diagnosis

INTRODUCTION

Poststernotomy mediastinitis is a rare feared sequelae of open-heart surgery with low incidence of 1% to 3% but a high mortality rate (10%-35%). Poststernotomy mediastinitis can in uncommon instances give rise to sternocutaneous fistulas in 0.25% to 10% of cases. Although scant reports have documented prosthetic valve endocarditis occurring in a setting of deep sternal wire infections, it is an infrequent but well-documented fatal complication of valvular replacement surgery.

CASE REPORT

A 52-year-old male smoker with aortic valve replacement (2011), on Coumadin and Monocor, was found dead on September 2013 with a hole along a surgical scar over the sternum, masquerading as a gunshot wound. Chest radiograph revealed no foreign body, and no evidence of homicidal/suicidal or accidental cause was found at autopsy. Examination revealed a chronic fistulous tract from a deep sternal wire infection to the skin, in addition to a chronic sinus tract eroding into the root of the aorta with recent prosthetic valve endocarditis.

DISCUSSION

To our knowledge, this is the first case report documenting poststernotomy mediastinitis causing a simultaneous occurrence of sternocutaneous fistula and prosthetic valve endocarditis. Either of these 2 exceptional but lethal complications would have sufficed as the cause of death.

Traumatic Bilateral Pneumothoraces due to Sternal Wire Migration

Sternal wound complications after cardiac surgery are associated with increased morbidity and mortality. Wire migrations associated with sternal dehiscence can lead to catastrophic haemorrhage unless intervened in time. We present a case of sternal wire migration causing bilateral pneumothoraces.

Pulmonary valve endocarditis caused by right ventricular outflow obstruction in association with sinus of valsalva aneurysm: a case report

Background

Right-sided infective endocarditis is uncommon. This is primarily seen in patients with intravenous drug use, pacemaker or central venous lines, or congenital heart disease. The vast majority of cases involve the tricuspid valve. Isolated pulmonary valve endocarditis is extremely rare. We report the first case of a pulmonary valve nonbacterial thrombotic endocarditis caused by right ventricular outlflow tract (RVOT) obstruction in association with a large sinus of Valsalva aneurysm.

Case presentation

A 60-year-old man with a six-week history of fever, initially treated as pneumonia and sinusitis with levofloxacin, was admitted to the hospital with a new onset of a heart murmur. An echocardiogram showed thickening of the pulmonary valve suggestive of valve vegetation. A dilated aortic root and sinus of Valsalva aneurysm measuring at least 6.4 cm were also identified. The patient was empirically treated for infective endocarditis with vancomycin and gentamycin for 28 days. Four months later, the patient underwent resection of a large aortic root aneurysm and exploration of the pulmonary valve. During the surgery, vegetation of the pulmonary valve was confirmed. Microscopic pathological examination revealed fibrinous debris with acute inflammation and organizing fibrosis with chronic inflammation, compatible with a vegetation. Special stains were negative for bacteria and fungi.

Conclusion

This is the first case report of a pulmonary valve nonbacterial endocarditis caused by RVOT obstruction in association with a sinus of Valsalva aneurysm. We speculate that jets created by the RVOT obstruction and large sinus of Valsalva aneurysm hitting against endothelium of the pulmonary valve is the etiology of this rare nonbacterial thrombotic endocarditis.