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Background and Aim of the Study: The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material., Methods: Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%)., Results: The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen., Conclusions: Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.

Objectives: Diagnosis of prosthetic graft infection after cardiac and proximal aortic surgery is a challenge. Besides technical considerations, redo surgery is associated with substantial morbidity and mortality. Therefore, an accurate diagnosis is mandatory. We report on our experience with hybrid 18-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET)/computed tomography (CT) imaging, which is increasingly used to diagnose infections in the detection of graft infection after cardiac surgery., Methods: Twenty-six patients who underwent (18)F-FDG PET/CT imaging after cardiac surgery between February 2010 and September 2014 for suspected graft infection were retrospectively analysed (81% male, age 54.3 ± 13.7 years). PET/CT imaging was performed 36.5 ± 70.5 (0.5-300) months after surgery. 2 patients (8%) had undergone aortic valve replacement (concomitant ascending and proximal arch replacement in 1), 1 (4%) aortic root reconstruction, 9 (35%) aortic root replacement (concomitant partial arch in 4, arch replacement and postoperative TEVAR in 1), 2 (8%) ascending aortic and partial arch replacement and 2 (8%) ascending aortic replacement along with frozen elephant trunk. In 10 (38%), more than one previous cardiac surgical procedure had been performed. Maximum standardized uptake values (SUVmax) were obtained for all patients. If the patients were reoperated on, the final diagnosis was derived from intraoperative findings and/or microbiological results. Otherwise, the longest clinical follow-up available served as a reference., Results: Conventional CT was positive for infection in 13 cases (50%). In 22 (85%), PET was indicative of infection (SUVmax 10.5 ± 4.1). PET did not only confirm true-positive CT results in all but 1 case; in almost 30%, it provided substantial additional diagnostic information in comparison with CT alone. Receiver operating characteristic analysis identified an SUVmax of 7.25 to achieve maximum sensitivity (89%) and specificity (100%) in prediction of infection. Twelve patients (46%) required redo surgery for graft infection; in 1 additional patient (4%), sternal re-fixation was necessary. Furthermore, 2 patients had to be reoperated on for torn-out anastomosis and paraprosthetic perfusion (8%)., Conclusions: PET provides functional data, confirms a CT diagnosis and may even increase diagnostic sensitivity in comparison with CT alone in selected cases. Specificity can be compromised by postoperative changes or chronic inflammatory reactions induced by the graft. CT and/or echocardiography should remain the first diagnostic step in case of a suspected infection because of their broad and fast availability. If confirmation is needed or diagnosis is not achievable using conventional methods, PET might be chosen as the next modality to gain additional information in experienced centres., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The management of infected Dacron grafts in the ascending aortic position involving the aortic arch and aortic root remains a technical challenge. Total replacement of the infected graft material with cryopreserved homografts appears to be an effective treatment strategy for these patients., Methods: Seventeen consecutive patients were operated on for infection of their ascending aortic graft where the aortic arch was also involved 26 ± 33 months after initial surgery, in 70%, for type A aortic dissection (12 acute aortic dissection type A and 1 chronic aortic dissection type A). The aortic root was additionally affected in 14 patients. Computed tomography and echocardiography follow-up was performed in all patients., Results: Hospital mortality was 24% (n = 4). Cardiopulmonary bypass and aortic cross-clamp times were 288 ± 128 and 165 ± 78 min, respectively. In 14 patients, the aortic root was replaced. Hypothermic circulatory arrest was necessary in all patients (41 ± 25 min) with additional cold selective antegrade cerebral perfusion in 14 (41 ± 30 min). During follow-up, 1 patient died due to a cerebral haemorrhage at 3 months and another at 4 years, of pulmonary embolism. Two patients were successfully reoperated on for degeneration of the aortic valve at 16 and 94 months; 1 patient had an early degeneration of the homograft and needed re-replacement with a homograft. In 2 other patients, a stent graft had to be placed to cover the distal anastomosis between the homograft and native aorta. In all others, recent follow-up revealed no degeneration of the implanted homografts., Conclusions: Surgery for infected Dacron grafts in the ascending aortic position with involvement of the arch can be performed with an acceptable perioperative mortality. In case of degeneration of the valve, reoperations can be performed with good results in experienced hands. Therefore, we consider the concept of complete explantation of all infected material and replacement with homografts a successful treatment strategy. Nevertheless, close follow-up of the patients is mandatory so as not to miss any degeneration or reinfection of the implanted grafts.

Background: To test the hypothesis that the oral cavity is a potential source for implantable pacemaker and cardioverter defibrillators infections, the bacterial diversity on explanted rhythm heart management devices was investigated and compared to the oral microbiome., Methods: A metagenomic approach was used to analyze the bacterial diversity on the surfaces of non-infected and infected pacemakers. The DNA from surfaces swaps of 24 non-infected and 23 infected pacemaker were isolated and subjected to bacterial-specific DNA amplification, single strand conformation polymorphism- (SSCP) and sequencing analysis. Species-specific primer sets were used to analyze for any correlation between bacterial diversity on pacemakers and in the oral cavity., Results: DNA of bacterial origin was detected in 21 cases on infected pacemakers and assigned to the bacterial phylotypes Staphylococcus epidermidis, Propionibacterium acnes, Staphylococcus aureus, Staphylococcus schleiferi and Stapyhlococcus. In 17 cases bacterial DNA was found on pacemakers with no clinical signs of infections. On the basis of the obtained sequence data, the phylotypes Propionibacterium acnes, Staphylococcus and an uncultured bacterium were identified. Propionibacterium acnes and Staphylococcus epidermidis were the only bacteria detected in pacemeaker (n = 25) and oral samples (n = 11)., Conclusions: The frequency of the coincidental detection of bacteria on infected devices and in the oral cavity is low and the detected bacteria are highly abundant colonizers of non-oral human niches.The transmission of oral bacteria to the lead or device of implantable pacemaker or cardioverter defibrillators is unlikely relevant for the pathogenesis of pacemaker or cardioverter defibrillators infections.

Background: Asymptomatic bacterial colonisation of medical implants is increasingly recognised. The role of the often unusual bacteria is usually unknown however., Objective and Methods: During a three-year period, patients presenting with clinically evident CIED lead endocarditis and/or pocket infections were included in a prospective database. Using 16s DNA analysis and sequencing, devices and pockets of consecutive patients with evident CIED infection were examined for the presence of bacterial species in addition to the ones grown in conventional culture in order to characterise their clinical role., Results: During the study 77 of a total of 409 consecutive operations involving the explantation of a CIED were performed for clinically evident infection. 71 were included in the study and conventional extended culture and 16s DNA analysis performed and compared. In 42.3% of the patients bacteria were identified by DNA analysis in addition to the culture of the supposedly causative organisms., Conclusion: DNA analysis is more sensitive than conventional culture of swabs in detecting any, or indeed multiple bacterial strains in CIED infection. This may in future influence treatment strategies as e.g. the cohabitation of different strains seems common and is not reflected by classical culture results. Spread of infection along the leads was clearly demonstrated and this strongly supports the recommendation of complete removal of all CIED components in every form of CIED infection. The more unusual bacteria demonstrated here do not appear to play a significant clinical role as suspected earlier.

We report a patient who presented with high fever; a unilateral, palpable tender swelling along the right shin; and effusions in knee and ankle joints leading to the diagnosis of hypertrophic osteoarthropathy (HOA). The diagnostic workup revealed an infected vascular graft that had been implanted 2 years before because of a ruptured infrarenal aortic aneurysm as the cause of HOA. The patient was treated successfully with antibiotics and surgically replacing the infected graft. Hypertrophic osteoarthritis is a clinical entity characterized by digital clubbing, periostitis, and synovial effusions. Primary and secondary forms have been described. Secondary HOA develops as a consequence of various diseases, mainly intrathoracic malignancies. Vascular graft infection, as reported here, is a rare cause of HOA. This case underlines the typical clinical features of HOA and the importance of a prompt and comprehensive diagnostic workup in cases of HOA. Our aim is to sharpen the awareness of its multiple underlying causes. Unilateral HOA is a rare but strong and important sign of infection of vascular prosthesis.

Objective: Pacemaker and implantable cardioverter defibrillator lead endocarditis mandates removal of all foreign material. In supposedly limited (pocket) infections, such a radical approach is still controversial. Thus, some patients are potentially exposed to persistent and recurrent infection because of retained material. Procedural risks and the success of eradicating infection were examined if involvement of the complete system was assumed in any cardiovascular implantable electronic device infection and complete removal was thus mandatory., Methods: A 12-year experience with 192 consecutive cases of bacterial pacemaker (152) or defibrillator (40) infections is presented. Complete removal of all prosthetic material was always aimed for. This was followed by antibiotic treatment for 4 to 6 weeks under temporary pacing if required, and then the new system was implanted. A total of 104 parameters concerning patient characteristics and operative and postoperative treatment were examined for their influence on outcome., Results: Infection was eradicated in 92.8% of patients. Recurrence was predominantly caused by failure to remove all prosthetic material (P < .001). If the protocol was strictly followed, infection was eradicated in 97.4% of patients. Conversely, 71.4% of patients with retained material showed recurrence. Further risk factors were poor dental hygiene and evidence of chronic subclinical infection. Morbidity and mortality of the interventional and open procedures were low. Open lead extraction was performed primarily in 34 patients (17.7%) and secondarily in 3 patients (1.9%). Temporary pacing and long-term antibiotic treatment were well tolerated., Conclusions: Complete removal of prosthetic material in any cardiovascular implantable electronic device infection is safe and associated with low morbidity and mortality. Success of eradicating infection is high if all system components are removed. Temporary pacing in dependent patients may be performed safely on an outpatient basis., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Increasing rates of bacterial infections in device therapy of cardiac rhythm disturbances pose a clinical problem. Radical surgical treatment yields the best long-term results but is frequently preceded by conservative treatment or limited surgical procedures leading to an unnecessary long treatment course. Recurrence/persistence of infection then potentially poses an even more serious clinical problem., Methods and Results: A total of 192 consecutive explantation procedures were performed for cardiac implantable electronic device (CIED) infections over a 10 year period. Forty-nine cases followed recurrence of infection subsequent to prior surgical treatment for device infection. Differences in patient/disease characteristics and outcome were looked for in recurrent as compared to primary infections (referral mode) to identify a potential requirement for adjusting treatment in recurrence. With a minimum follow-up of 24 months, 98% eradication of infection was observed independent of referral mode. Differences between primary and recurrent infection essentially reflected the primary presenting clinical picture-chronic smouldering vs. acute systemic infection. Various parameters that follow from this differentiation are significantly different between the groups. There was however no difference in outcome in terms of mortality and rate of recurrence. In addition, the parameters of the extraction procedure did not differ considerably., Conclusion: Despite significant differences in baseline and disease characteristics between primary and recurrent CIED infection, a standardized radical protocol results in an equally high success rate in eradicating infection in both groups. Nevertheless, direct and un-delayed referral of patients with suspected CIED infection to specialized centres is recommended as it saves time for the patient.

Aims: Recent work has been focused on causes of and risk factors for rhythm management device infections. The aim of this study was to elucidate whether patients may be asymptomatic carriers of bacteria on their rhythm management device, possibly allowing later manifestation of infection., Methods and Results: A total of 108 devices were changed for battery depletion between April 2005 and February 2006 in asymptomatic patients who were examined for evidence of bacterial DNA on the device and in the surrounding tissue using single strand conformation polymorphism analysis (SSCP). Follow-up was for 23.4 months. In 47.2% of the patients, bacterial DNA was demonstrated on the device, which had been in place for 64.1 months. The sequences identified bacterial strains that are untypical for clinical device infections. Staphylococci were demonstrated in only 3.7% of the patients and they became symptomatic within the observation interval; all others remained asymptomatic. The known risk factors for device infections did not correlate with the demonstration of bacterial DNA in this population. Common cohabitation was identified among the strains found., Conclusion: A large proportion of patients carry bacteria on their pacemaker or implantable cardioverter defibrillator asymptomatically. The strains found differ from those commonly seen in clinically evident device infections. Common risk factors for device infection did not correlate with the presence of DNA.

We report on the case of a young woman with a history of intravenous drug abuse and the development of an infection of a prosthetic supracoronary-, total arch and partial descending aortic allograft prosthesis following acute aortic dissection type Stanford-A two years previously. For surgical treatment we implanted an allograft prosthesis obtained from a local tissue bank. Particular variations in this setting and in comparison to conventional surgical planning were that high resolution computed tomography imaging was applied to determine and subsequently order the optimal allograft prosthesis in this individual patient and anatomical situation.