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• Management of cardiocutaneous fistulae
  Peter G Danias
  Published on: 9 January 2022
• Cardiocutaneous fistula following left ventricular aneurysmectomy
  Marco Pocar
  Published on: 9 January 2022

• Published on: 9 January 2022

  Management of cardiocutaneous fistulae

  • Peter G Danias, Cardiologist

  Dear Editor,

  We thank Dr. Pocar and his colleagues for contributing their experience with another case of cardiocutaneous fistula [1], which confirms several points that we and others have previously discussed [2] [3] [4]. The clinical presentation of cardiocutaneous fistula is usually slow and indolent but may rapidly deteriorate. Therefore, when this diagnosis is established elective operation should be perfo...

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  Dear Editor,

  We thank Dr. Pocar and his colleagues for contributing their experience with another case of cardiocutaneous fistula [1], which confirms several points that we and others have previously discussed [2] [3] [4]. The clinical presentation of cardiocutaneous fistula is usually slow and indolent but may rapidly deteriorate. Therefore, when this diagnosis is established elective operation should be performed without undue delay, to excise the fistulous tract and remove the infected foreign bodies. With medical therapy alone the infection cannot be eradicated. The natural progression of the disease may lead to catastrophic hemorrhage and grim outcome, as occurred in the case illustrated by Pocar M, et al. [1] and previous reports [3]. Meticulous surgical technique should always be employed during left ventricular aneurysm repair to prevent this rare but serious complication.

  Peter G. Danias, MD, PhD
  Cardiology Division, Department of Medicine
  Beth Israel Deaconess Medical Center and Harvard Medical School
  330 Brookline Avenue, Boston, Massachusetts 02215, USA

  Dr. Danias is partially supported by the Clinical Investigator Training Program: BIDMC - Harvard/MIT Health Sciences and Technology - Pfizer Inc.

  References

  1. Pocar M, Donatelli F, Grossi, A. Cardiocutaneous fistula following left ventricular aneurysmectomy. Heart Rapid Response, 17 May 2000.

  2. Danias PG, Lehman T, Kartis T, Missri J. Cardiocutaneous fistula. Heart 1999;81:325-326.

  3. Stanford W, Reuben CF, Flemma RJ, Mullen DC, Lepley D, Olinger GN. Management of long-standing cardiocutaneous fistulas after resection of left ventricular aneurysms. J Thorac Cardiovasc Surg 1980;79:789-792.

  4. Wellens F, Venermen H. Treatment of the infected cardiac suture line. J Card Surg 1988;3:109-118.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Cardiocutaneous fistula following left ventricular aneurysmectomy

  • Marco Pocar, cardiac surgeon
  • Other Contributors:
    • "Francesco Donatelli, Adalberto Grossi"

  Dear Editor:

  We read with great interest the review "Cardiocutaneous fistula" published by Dr. Danias and co-workers. At our Institution, we encountered a similar case, concerning a 72-year-old female, who developed this complication eleven months after coronary bypass sugery and linear resection of an anteroapical left ventricular aneurysm; the postoperative course had been complicated by mediastinitis necessit...

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  Dear Editor:

  We read with great interest the review "Cardiocutaneous fistula" published by Dr. Danias and co-workers. At our Institution, we encountered a similar case, concerning a 72-year-old female, who developed this complication eleven months after coronary bypass sugery and linear resection of an anteroapical left ventricular aneurysm; the postoperative course had been complicated by mediastinitis necessitating surgical debridement and irrigation with 0.5% povidone-iodine until removal of chest tubes. Initially, the patient presented mimicking subacute endocarditis and subsequently developed the fistulous tract from the cardiac apex through the chest wall. As stated by others [1] [2] [3] there was no tendency to spontaneous healing, and bleeding was only mild and transient, resembling chronic fistula secondary to chronic sternal osteomyelitis; cultures were negative. Elective operation was not planned because of poor general state and relative paucity of symptoms. Conditions gradually declined until, during hospitalization, massive hemorrhage ensued; no hemodynamic instability was observed during compressive maneuvers. Emergency operation was accomplished through re-sternotomy after institution of moderately hypothermic (28 °C) cardiopulmonary bypass through the femoral vessels. Cooling was continued during dissection of extremely dense adhesions and fragile tissues to obtain complete exposure the left ventricle, avoiding free dissection of the great vessels; the defect was repaired during circulatory arrest (20 °C) removing all foreign material and infected tissue along with two chronically eroded costal segments. The patient died on the fourth postoperative day in multi-organ failure.

  It is difficult to give guidelines, but some points should be stressed:

  High-risk surgery is probably the only therapeutic option and should be planned electively avoiding life-saving emergency operations.

  In our case, infection was not secondary to chest wall erosion due to prosthetic material (a theoretical possibility previously stated by others [3]). Mediastinitis may represent the inital cause, but also a consequence of implantation of contaminated prosthetic material during aneurysmectomy.

  The role of extensive use of prosthetic material (in particular, Teflon felt) outside the heart is unclear, but may be important. This specifically applies to patients undergoing left ventricular aneurysm repair, who often present additional risk factors for infection (advanced age, associated heart failure, longer cardiopulmonary bypass times, etc).

  In case of postoperative mediastinitis should extracardiac Teflon be replaced with autologous pericardium? This is a very difficult issue, due to the different extensiveness of surgical options, but may be important in the development of fistulae/pseudaneurysms of the heart/great vessels. In case of extensive use of prosthetic material, removal should probably be considered.

  Re-sternotomy [1] may not be the optimal approach for repair. If operation involves the left ventricle alone, an anterior thoracotomy through the 5th or 6th intercostal space [4] is more appealing and less cumbersome, despite the necessity of extrathoracic cannulation, deep hypothermia and low-flow bypass/circulatory arrest. Sternotomy may prolong surgery rather than represent a more expeditious technique. We reccomend to avoid re-sternotomy whenever possible, especially in case of previous mediastinitis.

  Marco Pocar, MD - Francesco Donatelli, MD - Adalberto Grossi, MD
  Istituto di Malattie dell'apparato cardiovascolare e respiratorio - Università degli Studi di Milano
  Divisione di Cardiochirurgia - IRCCS, Ospedale Maggiore Policlinico - Via Francesco Sforza, 35 - 20122 Milano, Italy

  References

  1 McHenry MC, Longworth DL, Rehm SJ, et al. Infection of the cardiac suture line after left ventricular surgery. Am J Med 1988;85:292-300.

  2 Stanford W, Reuben CF, Flemma RJ, et al. Management of long-standing cardiocutaneous fistulas after resection of left ventricular aneurysms. J Thorac Cardiovasc Surg 1980;79:789-792.

  3 Deuvaert FE, Wellens F, De Paepe J, at al. Cardiocutaneous fistula after left ventricular anuerysm repair. Case report and review of the literature. J Cardiovasc Surg (Torino) 1984;25:560-562.

  4 Wellens F, Vanermen H. Treatment of the infected cardiac suture line. J Cardiac Surg 1988;3:109-118.

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  Conflict of Interest:
  None declared.

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