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J Thorac Cardiovasc Surg 2000;119:403-404
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Cardiac aspergillosis

Servicio de Medicina Preventiva
Gurutzetako Ospitalea
Hospital de Cruces
Vizcaya, Spain

To the Editor:

Although nosocomial infection is decreasing in Spanish hospitals, ¹ a relative increase in infections caused by fungi is being noticed, which is similar to the tendencies found in other developed countries, ² and which implies a high rate of morbidity and mortality among immunodeficient patients. ³

Fungal endocarditis after cardiac surgery is rare, but when it occurs it is almost always fatal. ^4,5 As a truly effective treatment does not exist, prevention is vital. So that aerial infection in the operating room can be prevented while regulations for asepsis and epidemiologic controls are being fulfilled, it is recommended that the operating theater be acclimatized with a high degree of ambient biosecurity. ⁶

We report the case of a 54-year-old woman who was operated on in October 1998 in our specifically air conditioned cardiac operating room. The diagnosis was severe aortic stenosis and ascending aortic aneurysm (6 cm). She underwent prosthetic valve replacement with a St Jude Medical 21 HP prosthesis (St Jude Medical, Inc, St Paul, Minn) and replacement of the supracoronary ascending aorta with a 26-mm Dacron graft. Five days later, a VDD pacemaker was implanted because of episodes of complete atrioventricular block. Postoperative recovery was uneventful and she was discharged on the 10th postoperative day.

The operating theater was equipped with high-efficiency particulate air filter terminals and hyper-pressure with 25 air renewals per hour. All technical tests regarding both acclimatization and periodic ambient microbiological samples had been negative.

In January 1999, the patient came to the hospital with dyspnea, orthopnea, and a dry cough. On examination, bilateral jugular distention and facial edema were apparent. Transthoracic echocardiography, computed tomographic scanning, and aortography were performed, showing a huge mediastinal pseudoaneurysm around the aortic graft, with clots inside. There was no prosthetic leak. Because an infectious pseudoaneurysm was suspected, the patient was operated under deep hypothermic circulatory arrest and the aortic graft was replaced with another Dacron graft. Same-day microscopic examination of the explanted graft confirmed a fungal infection. Intravenous amphotericin was started, but the patient died of multiorgan failure. Cultures of the graft yielded Aspergillus flavus .

After diagnosis of endovascular aspergillosis, we started a follow-up of all the patients operated in this theater in the previous 3 months, but fortunately, there were no other cases. An epidemiologic survey was carried out to try to detect the source of the fungal infection: microbiologic samples from air (volumetric method), hardware, and filters were collected. All the cultures were negative except two samples collected in the dual reservoir cooler/heater (HemoTherm; Cincinnati Sub-Zero Medical Division, Cincinnati, Ohio), from which A flavus was isolated. Molecular typing of both strains from the exchanger and the strain from the graft was performed. The technique used was Random Amplified Polymorphic DNA (RAPD) against 8 control strains from other sources. All the strains (11) were analyzed with 3 different primers, AP12h, R-151, and R-108, to confirm the results. The strains from the heat exchanger (2) and the one from the graft showed 100% concordance whichever primer we used, thus allowing us to assert that we were dealing with the same strain of A flavus. ⁷

These results allow us to confirm the vent of the heat exchanger as the source of the aortic graft infection. Consequently, the heat exchanger should be considered as a possible source for fungal infection and should be taken into account in the control of ambient biosecurity in the cardiac surgery operating theater.

12/8/104342

References

1. Vaqué J. Evolución de la prevalencia de las infecciones nosocomiales en los hospitales españoles. Epine 1990-1997. Sociedad Española de Medicine Preventiva. Salud Pública e Higiene. Madrid, 1998.
   
2. Fridkin SK, Jarvis VR. Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 1996;9:499-511. [Abstract]
   
3. Torres-Rodríguez JM. Infecciones fúngicas invasivas. Med Clin (Barc) 1998;110:416-8. [Medline]
   
4. Rubinstein E, Noriega ER, Simberkoff MS, et al. Fungal endocarditis: analysis of 24 cases and review of the literature. Medicine 1975;54:331-4. [Medline]
   
5. Durack DT. Infective and non-infective endocarditis. In: Hurst JW, editor. The heart: arteries and veins. New York: McGraw-Hill; 1986. p. 1130-52.
   
6. Nichols RL. The operating-room. In: Bennet JV, Brachman PS, editors. Hospital infections. 4th ed. Philadelphia: Lippincott-Raven; 1998. p. 421-9.
   
7. Díaz Guerra TM, Mellado E, Cuenca-Estrella M, Gaztelurrutia L, Villate JI, Rodríguez-Tudela SL. Molecular typing of Aspergillus flavus isolates obtained from patient who underwent heart surgery and from surgical ward. Interscience Conference on Antimicrobial Agents and Chemotherapy. 39th ICAAC, San Francisco: September 26-29, 1999;
   

This article has been cited by other articles:

				I. El-Hamamsy, N. Durrleman, L.-M. Stevens, L. P. Perrault, and M. Carrier Aspergillus Endocarditis After Cardiac Surgery Ann. Thorac. Surg., July 1, 2005; 80(1): 359 - 364. [Abstract] [Full Text] [PDF]

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