Incision on chest not healed completely.

[pellicle]

Part of the scabs have fallen off twice. I don’t know if that’s good or not.

a normal process (have you never had a deep cut nor graze?)

This time I’m concerned about the sternotomy incision... It has a burnt match-looking scab on the top, and another scab on the bottom, and these haven’t really changed much since shortly after the surgery; except that the bottom one had a drop or two of whitish fluid come out after coming back from walks on three occasions, and a little tiny bit of blood after that. I just don’t know if this is normal, or if this kind of thing is a sign of infection.

scabs are normal, not changing is also proper, whitish fluid is something I've never seen, have you presented to a nurse or Dr?

yellow ooze is a sign of infection, as would be red and clearly irritated skin around it.

 

[Amy]

a sign of infection, as would be red and clearly irritated skin around it.

Thank you. The thing is, the skin is red (well, pink) and irritated around it. But I don’t know if some of that is still normal for 4 weeks post-op or not. Dang it. Wish I’d never seen Chuck C’s perfectly healed 18-day scar! lol

 

[Amy]

have you never had a deep cut

Apparently not! I try to live pretty cautiously, & get most of my adventures and exploring from books.

 

[Amy]

whitish fluid is something I've never seen

I don’t have a GP or a cardiologist at this point. I know I need to rectify that. And honestly, unless it’s absolutely necessary, I’m scared to go to the ER & have people who don’t wash their hands touching it. Judge me for that if you must.

 

[pellicle]

have people who don’t wash their hands touching it.

it does not look infected and as far as I know you can't get COVID by them touching your chest ... its a respiratory disease. Now if you then vigiorously rubbed where they'd touched and then sniffed your fingers that might do it

But I appreciate that in your age group one would wish to minimise exposure (to the air in) an ER

 

[pellicle]

PS: I believe I've shown this before, this is what (weeks after surgery) weeping infections look like

and from this you should be able to see the redness

in particular at the top compared to the bottom.

yours does not look like this

 

[Chuck C]

Yes, I had a feeling it could interfere with the warfarin, despite the nurse who called (telling me she’d call in the prescription) assuring me it would not.

She is incorrect. There is significant published literature on the way many antibiotics, including Cipro, interfere with warfarin and INR.

"In addition to interacting with warfarin via cytochrome P450-2C9, these antibiotics may also eliminate vitamin K-producing bacteria in the intestines to further alter INR"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116816/
Despite this, I have not yet seen any movement in my INR from Cipro. Perhaps I will after a few more days.

Let's compare notes on how Cipro affects INR and any other effects as we progress. However, I would not worry about it. It does some harm to our gut flora, but it is temporary. As he has shared, Pellicle has been on antibiotics for many years- about 10 or more I believe. Other than shrinking him to the size of Thumbalina, there are no observable negative side effects

 

[Amy]

Thank you, Pellicle.

It’s not COVID I’m worried about (although I probably should be) - it’s all the other crap like Staphylococcus aureus and MRSA, C. difficile...

 

[ATHENS1964]

https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-019-1000-1Although the incidence of sternal-related complications after sternotomy is low, the mortality rate is as high as 47% [6], and good sternal healing is closely related to a good quality of life [7]. Schimmer [8] reported that BMI > 30 kg/m2, heart function greater than NYHA III, renal insufficiency, peripheral arterial disease, an immunosuppressive state, surgical assistant closure of the chest, postoperative bleeding, infusion of plasma-reduced blood > 5 U, secondary surgery hemostasis, and surgery posterior malleous were risk factors for post-operative sternal complications. In addition, age > 42 years, a history of sternal surgery, > 2 arterial grafts (> 2 arterial conduits), internal mammary artery-free, BMI, chronic heart failure, diabetes, respiratory failure, and unexpected secondary surgery could lead to sterile sternal dehiscence [9]. A meta-analysis also indicated that a number of risk factors for sternal complications (OR values: 1.98 for female gender, 1.28 for smoking, 3.31 for diabetes, 2.59 for obesity, 3.11 for bilateral internal mammary artery grafting, 8.92 for secondary surgery, and 2.84 for transfusion) [6]. Furthermore, off-midline sternotomy was the cause of sternal dehiscence [10].

 

[Chuck C]

I don’t have a GP or a cardiologist at this point. I know I need to rectify that. And honestly, unless it’s absolutely necessary, I’m scared to go to the ER & have people who don’t wash their hands touching it. Judge me for that if you must.

I think you are doing the right thing in treating it seriously and taking antibiotics just in case. Having said that, it does not look infected to me. I have only had one sternal incision, and am very limited there obviously, but I have a lifetime of sports injuries and getting hurt in the outdoors with cuts and deep scrapes, and generally getting banged up a lot. To me your incision looks how a normal scab/cut looks. I think that you would have more redness if it was infected.

It is not surprising to me that part of your incision would be more scabbed up than the rest and taking longer to heal. I had two drain holes. One healed up relatively quickly, seemingly closed after about 2 weeks. The other one took about a week longer to heal. The difference: one scabbed up and the scab naturally fell off all on its own. The other one I accidently bumped the scab off while showering before it was ready to come off on its own. As a consequence it bled a little for about 3 days and re-scabbed. I was a little concerned that it was taking longer to heal, but the nurse practitioner looked at it during my follow up and said that it looked perfectly normal and not a concern that it had been recently bleeding a little.

 

[pellicle]

...

Just wondering if you went back through this thread and found this post
https://www.valvereplacement.org/threads/incision-on-chest-not-healed-completely.863369/post-863966

 

[Keithl]

https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-019-1000-1Although the incidence of sternal-related complications after sternotomy is low, the mortality rate is as high as 47% [6], and good sternal healing is closely related to a good quality of life [7]. Schimmer [8] reported that BMI > 30 kg/m2, heart function greater than NYHA III, renal insufficiency, peripheral arterial disease, an immunosuppressive state, surgical assistant closure of the chest, postoperative bleeding, infusion of plasma-reduced blood > 5 U, secondary surgery hemostasis, and surgery posterior malleous were risk factors for post-operative sternal complications. In addition, age > 42 years, a history of sternal surgery, > 2 arterial grafts (> 2 arterial conduits), internal mammary artery-free, BMI, chronic heart failure, diabetes, respiratory failure, and unexpected secondary surgery could lead to sterile sternal dehiscence [9]. A meta-analysis also indicated that a number of risk factors for sternal complications (OR values: 1.98 for female gender, 1.28 for smoking, 3.31 for diabetes, 2.59 for obesity, 3.11 for bilateral internal mammary artery grafting, 8.92 for secondary surgery, and 2.84 for transfusion) [6]. Furthermore, off-midline sternotomy was the cause of sternal dehiscence [10].

I was super anal during recovery. My doc said avoid any strain on sternum and no driving for 6 weeks and I did that. I slept propped up and on my back for most of that time and I could not tell I had a full crack. After 12 weeks (full healing) I was as good as new and to this day other than hearing the valve occasionally I would never know what I went through.

 

[kevanndo]

So...... someone please tell me about your similar experience!... I mean, is the four-week post-op mark too soon to be expecting the incision to not make a single drop of fluid with exercise? Or is the pec pain maybe related and to be taken seriously?

My daughter received a mitral valve replacement when she was nine years old. Six weeks post-op I noticed what looked like a large whitehead at the top of her incision site. I was worried about MRSA, so I took her to the pediatrician who lanced it and had it cultured. Thankfully, it was negative for any infection. For my own peace of mind, I'm really glad I took her in to the doctor's office because it definitely looked to me like it could have been an infection. This was a simple and painless procedure and something you might want to consider to put your own mind at rest.

I understand your concern with infection with hospital staff who refuse to use proper infection control. It is imperative that patients self-advocate, especially when it comes to proper protocol for sterilization. When a friend's newborn daughter was ready to have her surgical dressing removed after her open-heart surgery, the physician pulled a pair of scissors directly out of his coat pocket and immediately proceeded to cut the chest dressing without sterilizing the scissors. The baby ended up returning to the hospital for a 10-day course of IV vancomycin to combat the infection she had received at the incision site from the physician's scissors.

 

[Amy]

Hi @Keithl & @Chuck C - -
It sounds like you guys had such good support teams, willing to look at your scars, and give advice about what positions to avoid, etc... In comparison, I felt somewhat thrown into the deep end... No specifics unless I ask and ask and check and confirm and demand to know them... and sometimes not even then. Thank god for you guys on this forum, or.... well, I don’t really want to think about it. Thank you for sharing your experiences.

 

[Amy]

@kevanndo

These anecdotal horror stories... are just the thing right after breakfast. Thank you. (I have my own collection too, after a week in the hospital)

 

[Chuck C]

PS: I believe I've shown this before, this is what (weeks after surgery) weeping infections look like
View attachment 887792

and from this you should be able to see the redness

View attachment 887793

in particular at the top compared to the bottom.

yours does not look like this

Certain things.........you just can't unsee them once you've seen them But, we do a lot of show and tell here so it is all good. Serves as a good reminder to stay on top of the early signs of infection and get on antibiotics right away if needed.

 

[Chuck C]

Hi Amy,
I wanted to get back to you with my INR results, as promised, now that I am on day 4 of being on the antibiotic Cipro. My assigned target range is 2.5-3.5, but I personally try to stay between 2.5 and 3.0 and have mostly managed to do so.
My INR has been very consistent between 2.7 and 2.9 on 4mg of warfarin for the previous week. I've stayed at 4mg since going on Cipro and today tested at INR= 3.0. So, this would appear to be a very slight increase in INR, likely due to Cipro, but not nearly significant enough for me to consider changing my warfarin dose.
By comparison, in three days my INR went from 3.1 to 9.7 when I went on Amiodarone. At this point, it appears that Cipro is not moving my INR much, but will continue to monitor. I feel comfortable testing every other day now and will probably do so.

 

[Amy]

My assigned target range is 2.5-3.5, but I personally try to stay between 2.5 and 3.0

Thank you. Tell me again why your assigned target range isn’t 2.0-3.0?...

 

[Chuck C]

Thank you. Tell me again why your assigned target range isn’t 2.0-3.0?...

That's a good question which I will be asking my cardiologist, as I know that most with mechanical aortic valves have a target of 2.0-3.0.

 

[pellicle]

That's a good question which I will be asking my cardiologist, as I know that most with mechanical aortic valves have a target of 2.0-3.0.

if it helps my surgeon (its the surgeon who does the call in Oz, not the Cardio) wanted me to be min 2.2 so my range was effectively 2.2 ~ 3

I assume that he prefers 2.2 because if we account for margins of error he feels being above 2 is better than being below it. I happen to agree. Indeed if you take one of my yearly plots you'll find very few below 2 and the majority above 2.2

seems better than skating on the edge of the ice thickness