complications from mitral valve repair

[hayeryan1]

My husband (age 50) had mitral valve repair on March 17, 2008 and has since been readmitted two more times with a klebsiella infection from the fluid that had formed around his heart. It has been relayed to us that possibly because of high INR of 4.5 he bled and fluid starting building up.  They could not get fluid by needle aspiration and had to do surgery again to get fluid out as it had conjeeled.  It was then that we learned of the klebsiella and I also saw notation of MSSE.  He was discharged again only to be readmitted as the incision blistered up and once again had residual fluid under his breastbone that left an area of air after it was removed and they had to put in a wound VAC.  He also has atrial fibrillation with irregular PVC's which they were going to try cardioverting when they changed his wound vac this past Monday but decided to do at a later date.  In the last week he built up with fluid in his legs (gained 10 pounds in 4 days) and they intravenously administered Lasix during the wound vac change.  Echo notes also say he has 40% ejection fraction/mitral stenosis/mean gradient 5mmHg/peak gradient 14mmHg/mild mitral insufficiency/trivial tricuspid insufficiency/trivial pulmonic insufficiency.  There is distal anteroseptal and apical akinesis.  The basal and distal inferior walls are severely hypokinetic and there is severe left atrial enlargement.

It is my understanding that the fluid is building up due to the Afib.  If there is a drain tube from the wound vac could you also explain what they mean when they say that tissue needs to be built up in that area of space where fluid was removed and that this vac procedure will need to be done a few times.  He is on Vancomycin and Heparin and Amiodarone and Lopressor and K-Dur.  BP readings have been good.  Could you please explain all of this and your opinion of the A-Fib, fluid, infection (klebsiella and MSSE).  Thank you and sorry for such a long question.

[kenkeith]

It appears your husband has pericarditis and it is a swelling and irritation of the pericardium, the thin sac-like membrane that surrounds your heart. Part of the healing process would be to fill in the space after removal of fluids between sac and heart tissue.

Pericarditis can also develop shortly after a major heart attack due to the irritation of the underlying damaged heart muscle. In addition, a delayed form of pericarditis may occur weeks after a heart attack or heart surgery because of antibody formation and that may be the etiology.
Constrictive pericarditis. Some people with pericarditis, particularly those with long-term inflammation and chronic recurrences, can develop permanent thickening, scarring and contracture of the pericardium. In these people, the pericardium loses much of its elasticity and resembles a rigid case that's tight around the heart, which keeps the heart from working properly. This condition is called constrictive pericarditis and often leads to severe swelling of the legs and abdomen, as well as shortness of breath. This would be an explanation for a the 40% EF.

QUOTE:
"There is distal anteroseptal and apical akinesis.  The basal and distal inferior walls are severely hypokinetic and there is severe left atrial enlargement".

Constrictive pericarditis will cause LA enlargement as well as the gradient pressures. An enlarged can cause A-fib.  The distal anteroseptum and apical locations lacks wall movement.  That would reduce the EF as well.