Back to 2024 Display ePosters
Necrotizing Chest Wall Infection With Extension Into Breast Tissue Following Minimally Invasive Direct Coronary Artery Bypass Surgery
Adin S. Reisner, Robin Willard, Nirav C. Patel;
Lenox Hill Hospital, New York, NY, USA
This is a 60 year old female with obesity, hypertension, and poorly controlled diabetes who presented with non-ST elevation myocardial infarction and acute decompensated heart failure in the setting of severe two vessel coronary artery disease. She underwent robotic assisted minimally invasive direct coronary artery bypass after medical optimization. A skeletonized left internal mammary artery to left anterior descending anastomosis was created through a left anterior mini-thoracotomy. Exposure was challenging given her plethoric breast tissue, but the procedure and hospital course were uncomplicated, and she was discharged home on postoperative day 3. She attended multiple post-operative visits that only showed mild fungal infection on the inframammary fold near the healing surgical site. She then presented to the emergency department on post operative day 27 with fever, chills, and purulent discharge from a superficial dehiscence in her anterior thoracotomy incision. She was mildly hypotensive, and had leukocytosis, hyponatremia, and significant hyperglycemia of 453 mg/dL. She was admitted to the intensive care unit and managed with resuscitative fluids, broad spectrum antibiotics, and pressor support as needed. A CT scan revealed a large chest wall surgical site infection that extended from the chest wall into the breast tissue forming a 12 x 2.8 cm abscess cavity (Image 1). She initially underwent percutaneous drainage with interventional radiology and demonstrated improvement, but she continued to have copious purulent discharge despite a functioning percutaneous drain and worsening erythema and skin necrosis of the breast. She was taken for surgical debridement of devitalized tissue of the breast and chest wall on hospital day 3. This revealed an extensive cavity extending from the intercostal space of her thoracotomy and into the breast tissue all the way to the nipple. After serial wet-to-dry dressing changes, a wound vac was placed and long term intravenous antibiotic therapy initiated with strict glucose control. The patient continued to significantly improve and was discharged home on hospital day 10 with outpatient wound vac therapy and a plan for staged breast reconstruction 6 weeks from the initial debridement.
Back to 2024 Display ePosters
