感染性心内膜炎多瓣膜置换1例围术期观察

感染性心内膜炎可造成心脏瓣膜严重损害,导致心脏、肺脏功能及其他重要脏器功能障碍.瓣膜置换围术期并发症多、病死率高,术后观察十分重要.本文回顾性分析1例感染性心内膜炎多瓣膜置换手术患者围术期的临床资料,报道如下.     

感染性心内膜炎合并瓣膜病变的外科处理

目的探讨感染性心内膜炎合并瓣膜病变的外科处理方法。方法回顾性分析我院186例感染性心内膜炎合并瓣膜病变患者的临床资料,以发热就诊132例,心悸185例,术前血培养阳性86例。所有患者均在体外循环下进行赘生物清除及原发病手术,同期进行瓣膜病变处理,其中二尖瓣膜替换79例,二尖瓣成型16例,主动脉瓣置换45例,双瓣置换46例,三尖瓣成型90例,三尖瓣替换7例,术后根据血培养和赘生物培养结果选择敏感抗生素抗感染治疗4～6周。结果186例患者术后早期死亡10例（5．36％）,均因术后出现低心排或肾功能衰竭等并发症导致病情恶化死亡,其余均痊愈出院,术后主要并发症有低心排综合征15例,急性肾功能不全14例,肝功能损伤6例,上消化道出血5例,术后广泛出血延迟关胸1例。结论早发现、早诊断、早治疗,并掌握好手术时机和术后原则,感染性心内膜炎治疗可取得良好的效果。     

重症感染性心内膜炎33例围手术期的监护

目的：总结重症感染性心内膜炎患者围术期监护经验。方法：对33例复杂性心内膜炎行赘生物彻底清除心脏瓣膜置换术的患者加强围术期监护,做好患者心理及高热的护理,预防赘生物脱落;防治心律失常及低心排综合征,严防感染复发;认真做好健康指导是关键。结果：本组早期无死亡,无感染复发,瓣膜置换者无瓣周漏。结论：重症感染性心内膜炎加强围手术期监护,预防术后并发症,可提高手术成功率及患者的生活质量。     

瓣膜置换同期行改良CoxⅢ迷宫手术治疗风湿性心脏瓣膜病伴房颤患者的护理

目的 总结瓣膜置换同期行改良CoxⅢ迷宫手术治疗风湿性心脏瓣膜病伴房颤的护理效果和经验.方法 回顾分析2006年4月-2008年7月收治的58例瓣膜置换同期行coxⅢ迷宫手术的风湿性心脏瓣膜病伴房颤患者的护理措施. 结果 本组病例中围手术期因肾功能衰竭死亡1例,低心排死亡1例,感染性心内膜炎死亡1例,死亡率5.2%,其余均康复出院.在术后住院期间及术后短期随访中存活患者均为窦性心律.在完成术后6个月随访的43例患者中,有3例(7.0%)出现房颤心律,其余均保持窦性心律. 结论 对于瓣膜置换同期行迷宫手术的患者,护理上要注意术前的心理护理及呼吸道准备,术后加强对患者心功能的监护,注意抗凝治疗的护理.     

瓣膜置换同期行改良CoxⅢ迷宫手术治疗风湿性心脏瓣膜病伴房颤患者的护理

目的总结瓣膜置换同期行改良CoxⅢ迷宫手术治疗风湿性心脏瓣膜病伴房颇的护理效果和经验。方法回顾分析2006年4月-2008年7月收治的58例瓣膜置换同期行CoxⅢ迷宫手术的风湿性心脏瓣膜病伴房颤患者的护理措施。结果本组病例中围手术期因肾功能衰竭死亡1例，低心排死亡1例，感染性心内膜炎死亡1例，死亡率5．2％，其余均康复出院。在术后住院期间及术后短期随访中存活患者均为窦性心律。在完成术后6个月随访的43例患者中，有3例（7．0％）出现房颤心律，其余均保持窦性心律。结论对于瓣膜置换同期行迷宫手术的患者，护理上要注意术前的心理护理及呼吸道准备，术后加强对患者心功能的监护，注意抗凝治疗的护理。     

感染性心内膜炎的急症外科治疗

目的　总结感染难以控制、心功能进行性下降的器质性心脏病合并感染性心内膜炎患者急症外科治疗的经验和体会。方法　本组 2 0例均为感染难以控制、心功能进行性下降的器质性心脏病合并感染性心内膜炎患者 ,均行急症外科手术 ,彻底刮除感染灶 ,并用碘伏涂擦 ,然后矫治先天性心脏畸形。行单纯主动脉瓣置换 4例 ,二尖瓣置换 3例 ,双瓣同时受累 2例行瓣膜成形或换瓣术。术前高效抗生素应用时间 :(2 2± 17)天 ,均于感染活动期手术。结果　 1例法洛四联症根治术后室缺残余漏患者术后死于右心衰 ,病死率 5 % ,其余均痊愈出院。结论　感染性心内膜炎手术时机的掌握至关重要 ,对于严重败血症 ,感染难以控制 ,心功能进行性下降的患者宜急症手术 ,此时手术并不增加手术病死率。     

48例感染性心内膜炎的外科治疗

目的　总结 4 8例感染性心内膜炎的诊断、手术时机和疗效。方法　回顾分析 1991年 6月～2 0 0 2年 11月接受手术治疗的 4 8例感染性心内膜炎患者资料。合并原发心脏疾病 38例 ,其中先天性心脏病2 3例 ,风湿性心脏病 11例 ,二尖瓣脱垂和心脏术后各 2例。术前抗菌治疗 2例 (6 6 .2 7% ) ,血培养 2 3例 ,阳性7例 (30 .4 % ) ,以链球菌 (4例 )为主。超声心动图发现赘生物 35例 (72 .9% ) ,择期手术 4 2例 ;急诊手术 6例 ,其中难治性心力衰竭 3例 ,栓塞 3例。手术中清除所有感染灶 ,同期瓣膜置换 2 6例 ,心内畸形矫治和瓣膜成形 2 2例。结果　术后早期死亡 3例。术后主要并发症包括低心排综合征 4例、急性肾功能衰竭 3例、过量出血和切口感染各 2例。随访 30例 (6 2 .5 % ) ,随访期 1～ 10 6个月 ,平均 (6 4± 37)个月 ,无心内膜炎复发 ,心功能改善。结论　联合内科治疗和外科手术 ,感染性心内膜炎的疗效提高 ,对合并原发心脏畸形的患者出现难治性心力衰竭、感染控制困难等情况时 ,及时采取外科手术 ,可取得较好的治疗效果。     

先天性心脏病合并感染性心内膜炎30例诊治分析

目的:探讨先天性心脏病合并感染性心内膜炎的诊断及治疗。方法:回顾性分析30例先天性心脏病合并感染性心内膜炎患者的临床特点、手术时机、手术方法及疗效。结果:本组治愈率90%,病死率10%;术前1例死于脑栓塞,术后早期死亡2例分别死于心力衰竭和脑出血;术后随访3个月~5 a,心功能恢复良好。结论:先天性心脏病不明原因发热>1周应考虑感染性心内膜炎;掌握手术时机,选择合适术式,结合围手术期抗感染治疗可提高治愈率。     

重症心脏瓣膜术后肾功能不全CRRT的护理

目的 总结重症心脏瓣膜术后发生肾功能不全采用连续性肾替代(CRRT)护理经验.方法 收集2006年1月至2010年1月在我院治疗的重症风湿性心脏瓣膜病的患者15例,其中10例为主动脉二尖瓣联合瓣膜病,1例主动脉瓣膜病例,其余为二尖瓣合并三尖瓣瓣膜病变,术前心功能评估为3～4级,手术前后监测肾功和尿量,术后行床旁CRRT的治疗,监测肾功能.结果 除1例合并顽固性心衰死亡外,其余均治愈,最短5d,最长1月肾功能恢复.结论 重症心脏瓣膜术后肾功能不全行CRRT,加强术后护理和全面、准确的病情观察及判断可以有效降低瓣膜置换术后并发症发生率和死亡率,促进疾病的康复.     

感染性心内膜炎后急进性肾炎一例报道并文献复习

目的:探讨感染性心内膜炎后急进性肾炎的临床特点及预后。方法:报道1例感染性心内膜炎后I型急进性肾炎的患者,以"感染性"和"心内膜炎"以及"急进性肾炎"或"新月体肾炎"或"急性肾损害"为检索词在中外文主要数据库检索,筛选出感染性心内膜炎后急进性肾炎(肾脏病理确诊)患者的临床资料进行总结。结果:青年女性患者,RPGN出现在感染性心内膜炎、心脏术后半年,以进行性肾功能减退、抗GBM抗体阳性为特征,病理示新月体肾炎,予激素、免疫抑制剂等治疗,仍需肾脏替代治疗。检索文献,复习12例感染性心内膜炎后急进性肾炎病例,结果显示以中老年多见,肾脏病理示新月体肾炎,积极抗感染、激素等治疗,大多患者可恢复正常肾功能,部分患者仍需肾脏替代治疗甚至死亡。结论:感染性心内膜炎后I型急进性肾炎罕见,但若患者合并肾小球病变,建议肾活检以明确,早期干预、治疗,有利于改善预后。     

Echocardiographic detection of aortic valve ring abscesses

Valve ring abscess complication of infective endocarditis increases the expected morbidity and mortality rates of patients, but is seldom recognized by available noninvasive techniques. In our study, two-dimensional echocardiography successfully detected valve ring abscesses in eight patients with infective endocarditis affecting aortic valve prosthesis. Echocardiography showed the perivalvular abscess as an echo-free space in all patients. Prosthetic vegetations were seen in the only patient who had a biological prosthesis and excessive prosthetic rocking was observed in cases with severe aortic regurgitation. In two patients, the first echocardiographic examination showed an echo-free space without evident clinical signs of endocarditis or significant valve regurgitation. Severe aortic insufficiency and congestive heart failure followed the enlargement of the echo-free space. Valve replacement was required in all but one patient. The echocardiographic findings were confirmed at surgery. In one patient, the extension of the abscess to the interventricular septum was not detected by the echocardiography.     

Cryptococcal endocarditis of native valves without immunodeficiency or drug abuse: a case report

Cryptococcal endocarditis has rarely been reported. Most patients with this condition are associated with risk factors, such as structural heart disease/valve replacement, immunodeficiency/immunosuppression or drug abuse. We report a case of cryptococcal endocarditis of the native valves without any risk factors. A 50-year-old Chinese man was admitted to hospital with fever for 1 month without any underlying heart disease, immunodeficiency, or drug use. He was diagnosed as having Cryptococcus neoformans infective endocarditis and was discharged after valve replacement surgery and long-term antifungal therapy.     

Cardiac valve replacement in congestive heart failure due to infective endocarditis.

From January 1961 to July 1974, 138 patients underwent cardiac valve replacement because of complications of infective endocarditis. The overall operative mortality was higher in patients with Class IV cardiac functional disability (17%) than in patients with Class III (7%) or II (8%). The mortality for patients who had undergone aortic valve replacement with Class IV disability was higher (22%) than that for patients with Class III (0) or II (6%). When compared with patients without infective endocarditis who had undergone cardiac valve replacement, the operative mortality per valve replacement was approximately the same when the degree of cardiac disability was the same at the time of surgery for both groups of patients. Patients with aortic regurgitant murmurs caused by infective endocarditis should be observed closely for the onset of heart failure, especially during the first month of disease. In patients with aortic or mitral incompetence, if heart failure develops or progresses during the first month, we believe that prompt cardiac valve replacement should be considered, because even heart failure that may initially appear mild often progresses to severe heart failure during this period.     

3例经心尖行二尖瓣瓣中瓣手术老年患者的护理

总结3例二尖瓣置换术后老年患者经心尖行二尖瓣瓣中瓣手术的护理。护理内容如下。组建多学科照护团队,制订术前评估策略。术后监测血流动力学,改善心功能;优化气道管理,降低肺部并发症;监测凝血功能、肾功能,做好血糖管理,临时起搏器的护理,积极预防并发症的发生。实施多层面干预措施,改善患者预后。3例经过精心的治疗和护理,顺利出院,1个月后随访,恢复良好。     

Osteoarticular infection complicating enterococcal endocarditis

Despite the common occurrence of musculoskeletal complaints in patients with infective endocarditis, infectious osteoarticular complications are diagnosed infrequently. Moreover, although enterococcal infection is the third most common cause of infective endocarditis, infectious osteoarticular complications are rare. We report a case of disk space infection in a patient with enterococcal endocarditis. Blood cultures and an L3-4 aspirate grew Enterococcus faecalis, and transthoracic echocardiography revealed a large vegetation on the posterior mitral valve leaflet. The osteoarticular infection resolved with antimicrobial treatment, but worsening heart failure necessitated valve replacement surgery. The patient had an uneventful recovery with no evidence of recurrence or complications. A review of the medical literature from 1966 through 1998 identified 13 additional cases, only 8 of which provided clinical and treatment data. We present the clinical and laboratory findings reported in these cases, along with data from our patient. This report highlights the rare occurrence of osteoarticular infection in the setting of enterococcal endocarditis and emphasizes early recognition and treatment.     

Daptomycin therapy in 6 cases of left-sided infective endocarditis and literature review北大核心CSCD

Objective To evaluate the efficacy of daptomycin in the treatment of left-sided infective endocarditis after failing to respond to vancomycin. Methods A retrospective analysis was conducted for 6 cases of infective endocarditis. Results Five of the six infective endocarditis patients were complicated with paravalvular abscess (artificial valve in 3 cases, native valve in 2 cases). Their disease deteriorated even under vancomycin treatment. Four of these patients received emergency valve replacement surgery but still febrile after operation. The antimicrobial therapy was switched to daptomycin at dose of 6 mg/kg daily for 2 to 4 weeks. The patients responded satisfactorily to daptomycin. The infection was controlled to some extent in the fifth patient after switching to daptomycin, but recurred later, and died suddenly on day 21 after reoperation. The sixth patient had infective endocarditis of native valve, and had treated with piperacillin-tazobactam for 2 weeks and vancomycin for 3 weeks, but responded poorly. The patient still had fever and enlarged vegetation. Switching to daptomycin reduced the body temperature and vegetation. Serum creatine kinase elevated moderately in one patient, and normal in the other 5 patients. No other apparent adverse reaction was reported. One patient died and the other five patient survived well for 18 months to 5 years. Conclusions Preliminary observation demonstrates the efficacy of daptomycin salvage treatment in a few cases of left-sided infective endocarditis after failing to respond to vancomycin therapy. © 2018, Editorial Department of Chinese Journal of Infection. All rights reserved.     

Infective endocarditis in the pediatric patient: a 60-year single-institution review

ObjectiveTo determine the epidemiology of infective endocarditis (IE) presenting in pediatric patients during a 60-year period at our institution.Patients and MethodsIn this retrospective medical record review, we extracted demographic characteristics, diagnostic variables, and outcomes for patients less than 20 years of age diagnosed with IE from January 1, 1980, to June 30, 2011. We compared this cohort with a previously reported cohort of pediatric patients with IE from our institution diagnosed from 1950 to 1979.ResultsWe identified 47 patients (24 males; mean ± SD age at diagnosis, 12.3±5.5 years [range, 1 day to 18.9 years]) who had 53 episodes of IE. The most common isolated organisms were viridans streptococci (17 of 53 episodes [32%]) and Staphylococcus aureus (12 of 53 episodes [23%]). Of the 47 patients, 36 (77%) had congenital heart disease, 24 of whom had cardiac surgery before their first episode of IE (mean ± SD time to IE diagnosis after surgery, 4.2±3.2 years [range, 64 days to 11.3 years]). Fourteen patients (30%) required valve replacement because of valvular IE, and 16 (34%) had complications, including mycotic aneurysm, myocardial abscess, or emboli. Vegetations were identified using echocardiography in 37 of the 53 unique episodes of IE (70%). Endocarditis-related mortality occurred in 1 patient. Compared with the historical (1950-1979) cohort, there were no differences in patient demographic characteristics, history of congenital heart disease, or infecting organisms. One-year mortality was significantly lower in the modern cohort (4%) compared with the historical cohort (38%) (P<.001).ConclusionMost pediatric episodes of IE occur in patients with congenital heart disease. Mortality due to endocarditis has decreased in the modern era.     

Value of repeated multiplane transesophageal echocardiography in a patient with mitral valve ring abscess and left ventricular pseudoaneurysm.

Mitral valve ring abscess and ventricular pseudoaneurysm are rare complications of infective endocarditis. We describe the case of a 58-year-old man who was admitted to our hospital with sepsis caused by Staphylococcus aureus and in whom tricuspid and mitral valve endocarditis developed within 2 weeks. Despite widespread antibiotic therapy, the endocarditis proceeded to form a mitral valve ring abscess and a left ventricular pseudoaneurysm. The diagnosis was set by repeated multiplane transesophageal echocardiography and confirmed by heart surgery.     

Surgical pathology of the pulmonary valve: a study of 116 cases spanning 15 years

The gross surgical pathologic features of the pulmonary valve were reviewed in 116 patients (63 male and 53 female) who had undergone a cardiac operation with pulmonary valve excision at our institution during the period 1973 through 1987. Although the mean age was 12 years, subjects ranged in age from 3 months to 73 years, and 25 patients, including 19 with congenital heart disease, were older than 20 years of age. Among 105 patients who had pure pulmonary stenosis, 61 (58%) had tetralogy of Fallot, 18 had isolated pulmonary stenosis, 23 had other congenital cardiac anomalies, and 3 had carcinoid heart disease. Five patients had pure pulmonary regurgitation (four with tetralogy and one with infective endocarditis), and four had combined pulmonary stenosis and regurgitation (two with congenital cardiac anomalies and two with carcinoid heart disease). In two patients, the valve was neither stenotic nor regurgitant. Thus, congenital heart disease accounted for 110 of the 116 cases (95%), and tetralogy of Fallot was the most commonly observed form (65 cases). Bicuspid pulmonary valve was the most common anomaly and was present in 58% of patients with tetralogy but in only 17% of those with isolated pulmonary stenosis.