The Commando procedure for mechanical double valve prosthesis endocarditis with destruction of the aortomitral continuity
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Infective endocarditis, particularly after implanting valve prostheses, poses significant surgical challenges, often requiring complex interventions. We describe a case of a 37-year-old male with Staphylococcus aureus endocarditis, unsuccessfully treated with mechanical valve prostheses. Continued infection led to the destruction of the intervalvular fibrous body, necessitating a Commando procedure involving radical debridement and replacement of both aortic and mitral valves with complex patch reconstruction. Prosthesis selection remains contentious, considering recurrence risk and long-term prognosis. Our case underscores timely intervention and meticulous technique in managing such complex situations. It highlights successful strategies for treating infective endocarditis with destruction of aortomitral continuity, emphasizing the pivotal role of the Commando procedure.Keywords:
Infective Endocarditis
Debridement (dental)
Infective Endocarditis
Tooth brushing
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Debridement (dental)
Surgical debridement
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Two cases of infective endocarditis are reported. In both, vegetations on the cardiac valves characteristic of endocarditis were documented by echocardiography and confirmed at surgery in one of them. The various features of vegetative endocarditis on the echocardiogram are described. Differentiation of these echoes from those produced by other morbid states is discussed. Echocardiography is considered a useful non-invasive technique in the diagnosis of infective endocarditis. Cardiac surgery is usually found to be necessary in addition to medical therapy, when echoes characteristic of vegetative endocarditis are recorded by echocardiography.
Infective Endocarditis
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Prosthetic graft infection (PGI) is associated with low patient survival rates. The effectiveness of ultrasound debridement in chronic wound healing has been previously reported; however, data on the use of ultrasound technology and its effect on the treatment of PGI are still lacking. We report a case in which PGI in the groin was managed by graft removal using ultrasound debridement.A 70-year-old man was diagnosed with chronic limb-threatening ischemia and underwent a femoral-femoral bypass with a polytetrafluoroethylene graft. Eight months postoperatively, he developed an infection at the femoral incision site. Graft removal was performed using ultrasound debridement. The estimated blood loss was 10 mL. The wound healed, and the patient has remained in good health for 2 years postoperatively.When the ultrasonic probe is applied to the wound, ultrasonic energy penetrates into the tissue, and a fibrinolytic action removes necrotic or infected tissue without removing healthy tissue, thereby minimizing bleeding. Using this technique, we were able to perform effective debridement at not only the wound but also the anastomosis.It is our opinion that this technique can be used to achieve adequate debridement with little bleeding during graft removal and may provide a new option for the treatment of PGI.
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Abstract Objectives/Hypothesis: The aim of this randomized, partly blinded, controlled clinical trial was to evaluate the effects of debridement 6 and 12 days after endoscopic sinus surgery. Methods: Sixty patients (male/female = 26/34; mean age, 43.5 years; age range, 23–73 years) with chronic or acute recurrent rhinosinusitis were included. The patients were randomized to postoperative debridement or not. Primary outcome variables were adhesions between the middle turbinate and the lateral nasal wall 10 to 14 weeks after surgery judged by blinded evaluation of endoscopic video recordings. Secondary outcome variables were crusts in the nasal cavity 12 days after surgery and pain caused by debridement. Results: We found a significant reduction in adhesions in the group that underwent debridement ( P < .001). At 12 weeks, bilateral adhesions were observed in nine control patients but in only one debridement patient. Unilateral adhesions were found in 11 control patients and in nine debridement patients. Twelve days after surgery, we found significantly less severe crusts in the debridement group ( P < .01). Patients with severe crusts in the middle meatus 12 days after surgery had more adhesions 12 weeks postoperatively. The debridement group used more analgesics the days after the first debridement (3.7 days [standard deviation 2.3] vs. 2.3 days [standard deviation 2.6] in the control group, P < .041). Conclusions: Crusts in the middle meatus after sinus surgery is associated with postoperative adhesions. Debridement of the nasal cavity reduces crusts and postoperative adhesions significantly compared with saline irrigation only. However, the procedure induces more postoperative nasal pain.
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BACKGROUND The term “predisposition” is used as an indication of antimicrobial prophylaxis to prevent infective endocarditis and as a criterion for diagnosing infective endocarditis according to the modified Duke criteria. The criterion for diagnosing infective endocarditis in native valves is not well defined. OBJECTIVES To identify conditions that increase the risk for infective endocarditis in native valves, for the diagnosis of infective endocarditis according to the modified Duke criteria. In parallel, we compared the results with the year of patient inclusion for each study and echocardiographic techniques. RESULTS Our systematic review included 207 studies published from January 1970 to August 2015. Studies that focused on mitral valve prolapse (112 studies), prior infective endocarditis (96) and bicuspid aortic valve (78) provided the most data. However, only six (5.3%), three (3.1%) and one (1.3%) of these studies, respectively, used analytical statistical methods. Three (2.7%), two (2.1%) and one (1.3%), respectively, were graded as good quality studies. Odds ratios (ORs) for developing infective endocarditis were 3.5–8.2 for mitral valve prolapse, and 2.2 and 2.8 for prior infective endocarditis. The hazard ratio for developing infective endocarditis was 6.3 for bicuspid aortic valve. The mean prevalence proportion of infective endocarditis in patients with these three heart conditions were 8.5% (mitral valve prolapse), 8.3% (prior infective endocarditis) and 8.8% (bicuspid aortic valve). The proportions of publications prior to the publication of the modified Duke criteria were 81.8, 75.6 and 74%, respectively. Evolution of the imaging method and echocardiographic technique was estimated to be considerable for mitral valve prolapse. The literature review on aortic valve stenosis (46 studies), mitral valve insufficiency (41) and aortic valve insufficiency (39) provided two analytical studies for aortic stenosis. One study was graded as good quality and reported a hazard ratio 4.9. The mean prevalence of these heart conditions in patients with infective endocarditis were 7.3, 19.9 and 10.2%, respectively. The proportions of publications prior to the publication of the modified Duke criteria were 78, 75.6 and 79.5%, respectively. The evolution of both the echocardiographic technique and the categorisation of valve disease severity was considerable for all three entities. CONCLUSIONS The evidence for native valve heart conditions predisposing to infective endocarditis is mainly based on studies with only descriptive statistics published prior to the release of the modified Duke criteria. Mitral valve prolapse, prior infective endocarditis and bicuspid aortic valve are frequently cited as predisposing heart conditions for infective endocarditis. The evolution in echocardiographic techniques over the past decades and its influence on diagnosis was considerable for mitral valve prolapse, aortic stenosis, mitral insufficiency and aortic insufficiency.
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Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler’s nodes and Janeway lesions. We report a case of a women with infective endocarditis and the typical cutaneous manifestations. Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler’s nodes and Janeway lesions. We report a case of a women with infective endocarditis and the typical cutaneous manifestations.
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Despite advances in diagnosis and treatment, infective endocarditis remains a dangerous disease, particularly for people at risk because of a prosthetic valve, congenital heart disease, or a history of infective endocarditis, in whom morbidity and mortality approach 50%. 1 Prendergast BD The changing face of infective endocarditis. Heart. 2006; 92: 879-885 Crossref PubMed Scopus (216) Google Scholar Antibiotic prophylaxis for such patients at the time of invasive procedures has been a tenet of cardiac and dental practice for half a century, although the evidence of benefit is limited. Few cases of infective endocarditis are now secondary to oral streptococci, and Staphylococcus aureus (frequently acquired as a result of nosocomial infection or misuse of intravenous drugs) is now the most common pathogen, with attendant higher mortality. 2 Moreillon P Que Y-A Infective endocarditis. Lancet. 2004; 363: 139-149 Summary Full Text Full Text PDF PubMed Scopus (830) Google Scholar
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This chapter contains sections titled: Predisposing Cardiac Lesions Portals of Entry Organisms Responsible Diagnosis and Physical Signs Treatment Management Other Interventions and Infective Endocarditis Prevention of Infective Endocarditis Non-infective Endocarditis
Infective Endocarditis
HACEK endocarditis
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