Bacterial infection in heart

[slim110360]

My husband had his aortic valve replaced with a natural valve and also had an aortic aneurism wrapped with dacron mesh. He recently contracted a bacterial infection that got into his blood. It is being resistant to antiobiotics although the severe headaches and joint inflammation is gone. The high temperatures are less frequent. He has been on iv antibiotoics for 4 weeks and still spikes high temperatures about every 12-24 hours. His white cell count is still high.  The CT scan shows a shadow around the mesh. It could be scar tissue, clear fluid that's been there since surgery, or infection. Infection can many times result in another surgery to replace the mesh.  So the infectious disease doc is saying admit him again to the hospital and meet with the surgeon because the infection could compromise the mesh. The cardiologist says that's premature and let's get more info first on exactly what is around the area and has scheduled an MRI. Is it safe to wait for these tests? Not sure what to do although we're in the process of scheduling the MRI

[CCFHeartMD24]

This is a difficult situation, and the correct route to proceed varies on a patient-to-patient basis and involves the input of cardiologists, CT surgeons and infectious disease specialists. My understanding of your husband's situation is that he has a blood stream infection which appears poorly treated by antibiotics (given his persistent fevers and high white cell count), with the possibility of spread to this prosthetic mesh. However, whether or not the infection has spread to the mesh is still unclear based upon the imaging you have obtained thus far (the CT scan).

Your cardiologist appears to have made a reasonable suggestion in obtaining another imaging study which may provide further information (the MRI). A second open heart surgery does carry non-trivial risk, and thus your health care providers should have a very high suspicion of mesh infection before undergoing a repeat surgery. It is important to get as much information as is reasonably possible before making such a decision.

It's difficult to answer whether it is safe to wait for the scheduling of the MRI without having personally seen your husband. More information needs to be obtained before making the decision of proceeding to surgery; the question is whether this can happen as an outpatient or whether he should be admitted for closer observation during this time. A reasonable question to ask your cardiologist is something along the lines of "Is it safe to perform the MRI as an outpatient, or would you recommend having him undergo an expedited work-up in the inpatient setting"? It is also not unreasonable to get the opinion of a CT surgeon sooner, rather than later.

This is unfortunately not a question that can be answered easily via the internet, and my answer is merely a general recommendation; your husband sounds very ill, and this is a situation in which good recommendations can only come from knowing all the specifics of his history, doing a thorough physical exam and directly looking at all the imaging studies.  

[slim110360]

He did have a TEE which showed there was no damage to the valve. This may be why they then did the CT scan because they saw something around the mesh.  Problem is there was no baseline scan done right after surgery so the cardiologist said whatever they are seeing could have been there post op. There were 2 CT scans were done 2 weeks apart and showed no change. That's why the cardiologist said it could have been there since surgery.  The ID doctor said they could be the same because, if it is infected, it's not getting better. I will ask him tomorrow about other imaging studies to find other sources of infection. As you said, they need to be 110% certain it's in the heart because the surgery is high risk. This is incredibly frustrating and I do appreciate all your suggestions. I am worried but am really trying to be hopeful.

[CCFHeartMD24]

If your cardiologist and ID doctor are still in disagreement about whether an infection exists at the aortic mesh, another imaging study that may be helpful is called a transesophageal echocardiogram (TEE). Consider discussing this with your physicians.

In regards to pockets of infection elsewhere in the body, there are a number of different imaging studies available, but the best test in any situation will be specific to the patient. Your ID doctor should be able to discuss potential ways to work this up with you more tomorrow.

[slim110360]

So my husband had the MRI and the person who read the MRI said the shadow they are seeing around the heart is similar to what he's seen in other people who have had his type of surgery. He and my cardiologist are thinking the infection is not there.  Yet the ID doctor does not agree.  My husband's fever is back to normal and white blood cell is down to a 9 but over the weekend he seems to be experiencing inflammation in his achilles tendon and his thumb is swollen. We are seeing the ID dcotor tomorrow as well as the heart surgeon who performed his surgery. How can we find out if there is a pocket of infection somewhere else in his body?  He goes off IV antibiotics in 3 days and the ID doctor is putting him on suppression oral antibiotics.