McHenry M C, Longworth D L, Rehm S J, Keys T F, Moon H K, Cosgrove D M, Loop F D
Department of Infectious Diseases, Cleveland Clinic Foundation, Ohio 44106.
Am J Med. 1988 Sep;85(3):292-300. doi: 10.1016/0002-9343(88)90577-3.
Infections of the cardiac suture line after left ventricular surgery are rare but may be fatal if not diagnosed promptly and treated effectively. In order to alert physicians to this entity, we reviewed data from three patients who presented at the Cleveland Clinic Hospital and from 22 patients in the literature.
The three patients in the current report underwent treatment at the Cleveland Clinic Hospital. Additional cases of infection of the left ventricular suture line were identified by reviewing the English literature pertaining to surgery for left ventricular aneurysms, pseudoaneurysms, and postoperative cardiac infections.
Infection presented on average 16 months after surgery with cardiocutaneous fistulae, chest wall masses, hemoptysis or other pleuropulmonary symptoms, or systemic illness with bacteremia resembling endocarditis. Staphylococci and gram-negative bacilli were the most frequent pathogens. Diagnosis was often delayed and mortality was high. Left ventricular false aneurysms were identified in 15 of the 25 patients. Bleeding from sinuses in the chest wall or epigastrium or repeated hemoptysis were important clinical clues. In some instances, ill-advised surgical or instrumental procedures precipitated life-threatening hemorrhage. Treatment with antibiotics alone was insufficient. Excision of all infected sutures and Teflon pledgets and adequate debridement of the infected suture line were required to achieve cures.
Since infection of the left ventricular suture line has protean clinical manifestations and may present months or years after the initial surgery, a high index of suspicion is of paramount importance in diagnosing the condition. Institution of cardiopulmonary bypass and reoperation through median sternotomy is recommended to achieve a cure.
左心室手术后心脏缝线处感染较为罕见，但如果不能及时诊断并有效治疗可能会致命。为了提醒医生注意这一情况，我们回顾了在克利夫兰诊所医院就诊的3例患者以及文献中22例患者的数据。
本报告中的3例患者在克利夫兰诊所医院接受了治疗。通过回顾与左心室动脉瘤、假性动脉瘤手术及术后心脏感染相关的英文文献，确定了左心室缝线处感染的其他病例。
感染平均在术后16个月出现，表现为心皮瘘、胸壁肿块、咯血或其他胸膜肺部症状，或出现类似心内膜炎的菌血症等全身疾病。葡萄球菌和革兰氏阴性杆菌是最常见的病原体。诊断常常延迟，死亡率很高。25例患者中有15例发现左心室假性动脉瘤。胸壁或上腹部窦道出血或反复咯血是重要的临床线索。在某些情况下，不当的手术或器械操作会引发危及生命的出血。仅用抗生素治疗是不够的。要实现治愈，需要切除所有感染的缝线和特氟龙棉垫，并对感染的缝线部位进行充分清创。
由于左心室缝线处感染有多种临床表现，可能在初次手术后数月或数年出现，因此高度怀疑对于诊断该病至关重要。建议通过正中胸骨切开术建立体外循环并再次手术以实现治愈。
