Hybrid Repair with Reversed Sequence Supra-aortic Debranching in Ruptured Arch Aneurysm

Aortic arch pathology in a high-risk patient in whom the resternotomy approach is unfeasible due to treated mediastinitis after ascending aortic replacement presents a unique challenge for hybrid arch repair (HAR) because of the need for supra-aortic debranching from unusual inflow sites other than the ascending aorta. This report describes a “reversed sequence” extra-anatomical supra-aortic debranching procedure as a salvage technique performed to enable HAR. An 83-year-old woman with a history of ascending aortic replacement for type A aortic dissection, mediastinitis complicated by sternal osteomyelitis, and a chest wall reconstructed with a rectus abdominis myocutaneous flap presented with chest pain because of a contained dissecting arch aneurysm rupture. The patient underwent supra-aortic debranching from the bilateral common femoral arteries and thoracic endovascular aortic repair to the ascending aorta under cerebral near-infrared spectroscopy (NIRS) monitoring. Completion imaging by angiography demonstrated successful exclusion of the ruptured aneurysm. The regional cerebral oxygen saturation level, monitored by NIRS, did not change markedly during surgery. The patient was neurologically intact with adequate cerebral blood flow assessed postoperatively by 123I-IMP single photon emission computed tomography. Total debranching of the supra-aortic vessels from the common femoral artery for inflow is feasible and provides adequate cerebral perfusion. This procedure may offer an alternative treatment option in patients with complex conditions involving aortic arch pathology.

Presternal Scrofuloderma: Tip of the Iceberg Unveiling Multifocal Extrapulmonary Tuberculosis - A Rare Case Report

Introduction: Scrofuloderma, a type of secondary cutaneous tuberculosis (TB) commonly arising from the underlying cervical or axillary lymph node foci via contiguity, is frequent in the pediatric population. The origin of scrofuloderma from the underlying sternal tubercular osteomyelitic focus is exceptionally unusual. It can rarely be a part of the convoluted riddle of multifocal TB, particularly in the setting of human immunodeficiency virus (HIV) infection. Case Presentation: We hereby report a 16-year-old immunocompetent female who presented with chronic, sinus-like lesions with bridging scars on the upper chest, clinically confounded with infected keloid and deep fungal infection. She was later diagnosed with scrofuloderma arising from sternal osteomyelitis compounded with multifocal tuberculosis (sternal, mediastinal, cutaneous, lumbar vertebral) and received antitubercular treatment. Conclusions: This case highlights the importance of harboring clinical scepticism supported by thorough systemic investigations while diagnosing these innocuous mimickers occurring at rare sites, even in immunocompetent individuals.

A comprehensive surgical approach to the treatment of deep sternal wound infection after heart transplantation

Deep wound infection of the anterior chest wall tissues in patients after transsternal cardiac surgery despite intensive developments in surgical techniques and improvement of antibacterial chemotherapy, remains a genuine concern worldwide [1]. The incidence of this complication in the general population ranges from 0.5 to 4% [2, 3]. Despite developed approaches in the treatment of cardiac surgery patients, the treatment of deep sternal wound infection and surrounding tissues following a heart transplantation still remains a rather serious and pressing challenge. This paper presents a clinical observation of a heart transplant recipient, complicated by deep postoperative wound infection. The strategy of staged surgical treatment of sternal osteomyelitis consisted of surgical wound debridement, local wound debridement with vacuum dressings, and reconstructive surgery at the final stage (sternal reosteosynthesis, plasty of the anterior chest wall wound with displaced skin and fascial flaps).

SURGICAL TREATMENT OF COMPLICATIONS AFTER STERNOTOMY

Summary. The article presents materials of laboratory and instrumental diagnostics of 44 patients with sternal osteomyelitis and comparative treatment with VAC - therapy and open method. Diagnosis was verified by multispiral computed tomography. Ultrasound showed the best results to control the cleaning and healing of sternotomy wounds. The bacterial spectrum showed a predominance of gram-positive microflora in 52.38 % of patients. The use of VAC therapy reduced the duration of hospitalization of patients from (20,3±2,7) to (13,6±5,8) days. Materials and methods. We analyzed the results of treatment of 22 patients who were treated at the State Institution “V.T. Zayceva IGUS NAMSU “in the period from 2014 to 2020 with osteomyelitis of the sternum (OS) after sternotomies. The material for the bacterial study was the isolation of a sternal wound. The antibiotic susceptibility of the isolated bacterial cultures was studied by disco-diffusion method and on agar. Diagnosis of multislice computed tomography (MSCT) was performed using Toshiba Aquilion 64 (Japan). Results and discussion. Wound infection was detected in 42 patients out of 44 examined. A total of 34 strains of microorganisms, representatives of different taxa. S. aureus was dominant and accounted for 23.81 % of the total number of isolates of this genus. In 14.28 % of cases there was contamination of S. epidermidis. E. coli and K. pneumonia 14.28 and 9.52 %, respectively. The most effective in vitro were lincomycin and especially carbopenems (imipenem). Among the instrumental studies we performed fistulography, ultrasound diagnostics (ultrasound) and MSCT. We used VAC therapy in 31 patients and in 13 patients by bandaging depending on the stage of the wound process. The duration was (4.7 ± 1.3) days. There was a decrease in the duration of wound cleansing: with superficial sternal infection — (12.8 ± 5.2) and (4.7 ± 1.3) days; with deep sternal infection — (25.3 ± 1.4) and (10.9 ± 2.2) days; term of hospitalization of patients with superficial sternal infection — (27.3 ± 5.6) and (13.6 ± 5.8) days; term of hospitalization of patients with deep sternal infection — (41.2 ± 3.5) and (20.3 ± 2.7) days. Conclusions. 1. In the diagnosis of OS should be preferred MSCT, which allows to verify the diagnosis in up to 99 % of cases, and the use of ultrasound to monitor the cleaning and healing of sternotomy wounds. The use of VAC therapy reduced the duration of hospitalization of patients from (20,3±2,7) to (13,6±5,8) days.

Competence Mining of Vancomycin (VAN) in the Management of Infections Due to Bacterial Strains With High VAN Minimum Inhibitory Concentrations (MICs): A Novel Dosing Strategy Based on Pharmacokinetic/Pharmacodynamic Modeling

The increasing emergence of bacterial strains with high VAN MICs (BSH–VAN–M), such as Enterococcus faecalis, Enterococcus faecium, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus bovis, results in growing concern that VAN is not effective against these isolates. Due to the limited data on VAN against BSH–VAN–M and the application limits of drugs currently considered to be effective for BSH–VAN–M, exploration of “new usages for old drugs” is reasonable to improve and maximize the efficacy of existing antibiotics. This study aimed to construct a novel dosing strategy to mine the competence of VAN in the management of BSH–VAN–M infections. Herein, we optimized the traditional intermittent i.v. infusion (TIII) method to create an optimal two-step infusion (OTSI). With pharmacokinetic (PK)/pharmacodynamic (PD) modeling at the targeted ratio of the daily area under the concentration-time curve (AUC0–24) to the minimum inhibitory concentration (MIC) (AUC0–24/MIC) of 400, we used Monte Carlo simulations to evaluate the efficacy of 25 VAN regimens (including 15 OTSI regimens and 10 TIII regimens with daily doses of up to 6 g) to treat pneumonia, meningitis, sternal osteomyelitis, mastitis, pleuritis, bacteremia, and bacterial pericarditis resulting from isolates with MICs of ≤64 mg/L and to the current E. faecalis, E. faecium, S. aureus, S. epidermidis, and S. bovis populations with a pooled MIC distribution. Our data indicated that 4 g/day VAN, with an OTSI but not a TIII, for mastitis, pleuritis, bacteremia, and bacterial pericarditis due to isolates with MICs of ≤4 mg/L or to the current E. faecalis, S. aureus, S. epidermidis, and S. bovis populations achieved the desired PK/PD exposure at the AUC0–24/MIC target of 400. This study suggests the superiority and feasibility of OTSI relative to TIII for the competence mining of VAN against BSH–VAN–M from the perspective of PK/PD and provides a new resource for understanding how PK/PD modeling shapes the performance of VAN to meet the growing challenges of BSH–VAN–M infections.

Sternectomy for Candida albicans sternal osteomyelitis after left ventricular assist device implantation

Fungal osteomyelitis is an uncommon complication after cardiac surgery and associated with high mortality. A case of Candida albicans and Staphylococcus epidermidis osteomyelitis with device infection after implantation of a left ventricular assist device in a 60-year-old male patient is presented here. After clinical identification and confirmation with microbiological examinations and fluorodeoxyglucose positron emission tomography (FDG-PET) scan, debridement was performed. Surgical specimens grew C. albicans and S. epidermidis. Fluconazole, daptomycin, and negative pressure wound therapy were initiated, but failed to achieve healing. Total sternectomy and pectoralis flap reconstruction were performed. There was no recurrent infection for C. albicans on a prolonged antifungal regime. The combination of antifungal therapy and aggressive surgical debridement may be useful to control fungal osteomyelitis.