Aspergillus endocarditis after cardiac surgery

Aspergillus species infections are an increasingly common occurrence in hospital wards. Aspergillus endocarditis constitutes one of the manifestations of the disease, which bears a poor prognosis in cardiac surgery patients. A review of the literature on fungal and Aspergillus endocarditis was undertaken. Valvular risk factors, indwelling intravenous catheters, prolonged antibiotics, malignancy, and intravenous drug use increase the risk. Clinical presentation is insidious, with embolic complications often representing the first manifestation of the disease. Blood cultures are typically negative. The mortality rate is almost 100%. Amphotericin B represents the mainstay of medical therapy with several possible adjuncts. Surgery is an essential part of therapy in Aspergillus endocarditis after cardiac surgery and should be undertaken as soon as the diagnosis is made. Aspergillus endocarditis is an ominous complication after cardiac surgery. A high suspicion index, early administration of appropriate antibiotics, and prompt surgical intervention should improve the prognosis, which remains dismal.     

Takotsubo syndrome after cardiac surgery

We have not found any reports to date of Takotsubo syndrome after cardiac surgery. Recently described Takotsubo syndrome is characterized by acute reversible left ventricular dysfunction with apical ballooning in the absence of coronary artery disease, and with chest pain and electrocardiographic changes mimicking acute anterior myocardial infarction, but with minimal release of myocardial enzymes. We describe Takotsubo syndrome that developed after elective mitral valve replacement and tricuspid annuloplasty in a 62-year-old woman. On supportive therapy with vasopressors, left ventricular function gradually improved with an ejection fraction returning to 50%. Takotsubo cardiomyopathy should be considered as a possible complication of the cardiac surgery.     

Severe ischemic early liver injury after cardiac surgery

BACKGROUND: The epidemiology, pathogenesis and prognosis of severe ischemic early liver injury (SIELI) after cardiac surgery are poorly understood. Accordingly, we studied patients whose alanine transaminase (ALT) concentration acutely increased above 500 IU/l in the immediate postoperative period and compared these patients to two control groups matched for preoperative and immediate postoperative characteristics. METHODS: We used a prospective database of 1,800 consecutive cardiac surgical cases to identify the study groups. Group I was made up of 20 patients with ALT levels above 500 IU/L in the acute postoperative stage (SIELI). Preoperative liver tests were normal in all these patients. Group II was obtained by identifying 20 control cases whose age, type of surgery, NYHA classification, and Parsonnet score matched Group I (preoperative controls). Group III was obtained by identifying 20 patients who developed postoperative acute renal failure and shock (ARF/shock; postoperative controls) but no enzyme evidence of hepatic injury. RESULTS: Acute renal failure, a low cardiac index (CI) state, and mortality were more common in SIELI and ARF/Shock patients compared with preoperative controls (all p values less than 0.01). Peak postoperative pulmonary artery occlusion (PAOP) and central venous (CVP) pressures were also higher in SIELI and ARF/Shock patients than controls (all p values less than 0.02). A higher dose of norepinephrine and milrinone were required to maintain blood pressure and cardiac output in SIELI and ARF/shock patients than preoperative controls (all p values less than 0.005). SIELI patients, however, differed from ARF/Shock patients in that they had a higher preoperative NYHA class and a greater incidence of hypertension and diabetes. Stepwise linear regression analysis identified a postoperative low CI and the presence of diabetes as the only predictors of peak ALT value (p less than 0.05). Multivariate logistic regression analysis identified female gender as being associated with a higher likelihood of SIELI (odds ratio: 6.13; 95% CI 1.08 to 34.82) CONCLUSIONS: SIELI after cardiac surgery carries a high mortality and is strongly associated with a low cardiac output and increased filling pressures, suggesting that liver ischemia induced by a combination of decreased perfusion and congestion is fundamental to its pathogenesis. A history of cardiac failure, diabetes, hypertension, and female gender may represent risk factors for its development and severity in the setting of a postoperative low cardiac output state.     

Effect of prior malignancy on survival after cardiac surgery

BACKGROUND: The number of patients with a previously treated tumor, needing cardiac surgery is increasing. Whether this operation in these patients is justified is determined by the long-term outcome. METHODS: Of 8620 patients referred for cardiac surgery, 205 had a documented malignant tumor. The time interval between the occurrence of the tumor and the cardiac surgery was recorded. These patients were matched with 205 patients without a tumor according to age, gender, comorbidity and type of cardiac surgery. The patients were followed retrospectively. A chi(2) Kaplan Meier and Cox' regression analysis were performed. RESULTS: During follow-up, 95.8% of the patients were traced (2794 patient years). Univariate analysis showed that 5- and 10-year survival was better in patients without a malignant tumor in the history (0.91 +/- 0.02 versus 0.72 +/- 0.03 and 0.73 +/- 0.04 versus 0.40 +/- 0.05; p < 0.0001). For shorter time intervals, mortality for all causes and mortality due to the tumor increase significantly (p < 0.0001). Multivariate analysis identified 4 independent variables: a malignant tumor in the history (p < 0.001), chronic obstructive pulmonary disease (p = 0.003), age (p = 0.001), and impaired left ventricular function (p = 0.035) CONCLUSIONS: A malignant tumor in the history is the most prognostic factor after cardiac surgery, but the operation is still rewarding. Fatal progression of the tumor is seen if the time interval between the occurrence of the malignant tumor and cardiac surgery is short. Other unfavorable factors are decreased left ventricular function, chronic obstructive pulmonary disease and high age.     

Vertebral osteomyelitis

Vertebral osteomyelitis (VO) is an infectious disease of the vertebral body that requires early diagnosis with identification of the infecting organism to direct antibiotic therapy. Most VO can be treated nonsurgically, but 10% to 20% of cases require open surgical treatment. Excellent clinical outcomes can be achieved with appropriate medical and surgical treatment.     

Effectiveness of hyperbaric oxygen therapy for hearing loss after cardiac surgery

Sudden sensorineural hearing loss is a rare complication after cardiac surgery with extracorporeal circulation. We report a case of a 60-year-old man who experienced severe sensorineural hearing loss after Bentall procedure and recovery of normal hearing after 20 days of hyperbaric oxygen therapy.     

Pyrexia after cardiac surgery: natural history and association with infection

Background

Pyrexia is common after major surgery, and infection is often an important consideration. To investigate the natural history and association with infection, we performed a prospective observational study.

Methods

From November 2000 to January 2001, we studied 219 patients undergoing cardiac surgery screening daily for wound, respiratory, urinary tract, and other infections. Pyrexia was defined as temperature above 37.5°C.

Results

Of 219 patients, 7 intraoperative deaths occurred and 1 patient was excluded because of preoperative endocarditis, leaving 211. The mean age (SD) was 64 (10) years, consisting of 172 male patients (81.5%). The proportion pyrexial on days 1, 2, and 5 was 30.0%, 25.8%, and 10.3%, respectively. More patients undergoing urgent or emergency procedures (17.7% versus 7.8%; P = .03) subsequently developed pyrexia. However, there were no differences in wound infection (3.4% versus 8.3%; P = .13), positive cultures for respiratory (14.7% versus 11.4%; P = .16), urinary tract (5.2% versus 2.0%; P = .09), or other infection (8.6% versus 7.3%; P = .71) in patients experiencing postoperative pyrexia compared with those who did not.

Conclusions

Pyrexia is common after cardiac surgery and resolves in the majority of patients by day 5. Because there is no association between early pyrexia and infection, diagnosis of early postoperative infection by pyrexia alone is insufficient and is better established by clinical assessment with microbiological evidence.