Getting to a man’s heart through his colon

A 69-year-old man presented with a progressively enlarging pulsatile mass in the left side of his chest. Because of a history of an ischemic cardiomyopathy, he had been randomized in 2003 to undergo coronary artery bypass grafting with a Dor procedure, as part of the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Our patient’s imaging studies, including a thoracic computed tomogram and transthoracic echocardiogram, were now of concern for left ventricular pseudoaneurysm. He was taken immediately for surgical exploration. Purulent material, with empyema, extended from the anterior chest wall through the chest cavity into the mediastinum, with communication into the pericardial space. Notably, there was no compromise of the left ventricular cavity, and there was no pseudoaneurysm. The chest was copiously irrigated before closure. The epicardial patch placed 10 years earlier in the STICH trial was not thought to be the nidus of the abscess and was therefore not removed. Three months later, the patient presented again, this time with hemorrhagic shock and bleeding from his left anterior thoracotomy site, which we then re-entered. He was found to have a left ventricular pseudoaneurysm with disruption of the ventricular apex. The epicardial felt-and-Dacron patch, placed 10 years previously during his Dor procedure, was found to be infected with Clostridium difficile and was removed. The left ventricular apex was repaired. Whereas C. difficile bacteremia is rare, the seeding of prosthetic cardiac material with delayed presentation, as in this case, is extraordinarily uncommon.