Commentary: Recurrent xenopericardial elephant trunk graft infection: Snatching victory from the jaws of defeat
Bibliographic record
Abstract
Central MessageLarge vegetation of a xenopericardial elephant trunk graft is an unusual cause of aortic obstruction.See Article page 46. Large vegetation of a xenopericardial elephant trunk graft is an unusual cause of aortic obstruction. See Article page 46. In this edition of the Journal, Minegishi and colleagues1Minegishi S. Inaba Y. Endo H. Kubota H. A large vegetation on a xenopericardial roll elephant trunk graft.J Thorac Cardiovasc Surg Tech. 2021; 6: 46-49Scopus (2) Google Scholar present a patient who underwent total arch replacement with elephant trunk for type A dissection. She developed an Enterobacter cloacae graft infection and underwent redo total arch replacement with xenopericardial roll graft. She then developed fungal infection of the elephant trunk with a near-occlusive vegetation and had redo-redo-descending aortic replacement via left chest. To our knowledge, this is the first report of a massive vegetation on an elephant trunk as a cause of near occlusion. That this surgical team successfully performed 3 high-risk operations is a tour de force and a tribute to the resilience of the surgical team and indeed the patient. Thoracic aortic prosthetic graft infection has an incidence of less than 3% but is associated with 25% to 75% mortality.2Tossios P. Karatzopoulos A. Tsagakis K. Sapalidis K. Grosomanidis V. Kalogera A. et al.Treatment of infected thoracic aortic prosthetic grafts with the in situ preservation strategy: a review of its history, surgical technique, and results.Heart Lung Circ. 2014; 23: 24-31Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar There is limited evidence to guide management, although some strategies include a combination of (1) reoperation with aggressive debridement and aortic replacement with a rifampin-soaked Dacron graft, homograft, or xenopericardial graft; (2) coverage with native tissue (eg, omental) flap; (3) local antibiotic infusion; (4) life-long suppressive antibiotics; and (5) wound drainage with or without negative-pressure dressings.3O'Connor S. Andrew P. Batt M. Becquemin J.P. A systematic review and meta-analysis of treatments for aortic graft infection.J Vasc Surg. 2006; 44: 38-45Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar Familiarity with the range of therapeutic options, and flexibility in modifying the plan in the face of unanticipated challenges, is key. In the absence of robust evidence, guidelines for similar conditions can be instructive. The American Heart Association recommends that patients with fungal endocarditis receive parenteral antifungal therapy with amphotericin B plus an additional antifungal agent for a minimum of 6 weeks, followed by consideration of lifelong oral azole therapy.4Baddour L.M. Wilson W.R. Bayer A.S. Fowler Jr., V.G. Tleyjeh I.M. Rybak M.J. et al.Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association.Circulation. 2015; 132: 1435-1486Crossref PubMed Scopus (1258) Google Scholar Guidelines for intra-abdominal graft infections suggest the use of biologic over prosthetic material. They suggest use of arterial allografts over venous autografts due to the morbidity associated with vein harvest and wound healing, and suggest the use of rifampin- or silver-soaked synthetic grafts.3O'Connor S. Andrew P. Batt M. Becquemin J.P. A systematic review and meta-analysis of treatments for aortic graft infection.J Vasc Surg. 2006; 44: 38-45Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar,5Wilson W.R. Bower T.C. Creager M.A. Amin-Hanjani S. O'Gara P.T. Lockhart P.B. et al.Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association.Circulation. 2016; 134: e412-e460Crossref PubMed Scopus (165) Google Scholar The basic principle of all infected prosthetic materials is source control with removal of all infected tissue and aggressive debridement. As always, a multidisciplinary team is recommended to include vascular and cardiothoracic surgeons, cardiologists, infectious diseases specialists, and radiologists, so that where evidence is lacking, clinical decision-making can benefit from broad expertise and collaboration. We thank the authors for sharing this rare presentation of graft occlusion by massive vegetation, and we congratulate the authors on their heroic and innovative surgical strategy which is instructive for those encountering similar challenging scenarios. A large vegetation on a xenopericardial roll elephant trunk graftJTCVS TechniquesVol. 6PreviewElephant trunk (ET) graft infection is a rare complication.1 We present the uncommon case of a large vegetation on an ET, which almost totally occluded the lumen during the late postoperative period. Full-Text PDF Open Access
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".