感染性心内膜炎的外科治疗

目的 分析感染性心内膜炎的诊断、手术时机和疗效。方法 7例感染性心内膜炎均接受手术治疗。合并先天性心脏病1例,风湿性心脏病4例。术前均经抗菌治疗2周以上。血培养阳性2例,均为链球菌。超声心动图发现赘生物6例,脾脓肿1例。手术中清除所有病灶,同期瓣膜置换6例,心内畸形矫治1例。结果 术后死亡2例。术后并发症包括急性肾功能衰竭1例、脑出血1例及瓣周漏1例,其他患者随访至今无心内膜炎复发,心功能改善。结论 感染性心内膜炎早期诊断,适时外科手术和内外科联合治疗是治疗成功的关键。     

New developments in the treatment of infective endocarditis infective cardiovasculitis

The natural history of infective endocarditis has undergone remarkable changes over the past 100 years as regards both the demographic characteristics of the disease and changes in the incidence of the so-called diagnostic signs. Alongside these changes and the development of new and better diagnostic tools and criteria, we are also facing new problems with the precise definition of cardiovascular infections and calculation of the incidence of the disease. Nosocomial endocarditis presents an emerging problem of diagnosis and treatment after heart valve surgery, with pace-maker catheters, defibrillators and a very large variety of foreign materials used in connection with heart valve surgery. New technological progress including new types of prosthetic valves and use of homografts or the Ross operation will give a greater possibility of choosing the best solution in a particular case. Antimicrobial chemotherapy is mainly based on our understanding of the pathophysiology of the disease and efficacy of the antibiotics achieved in an experimental animal model of endocarditis. Important recommendations of single or combined drug therapy or the dosing regimens of antibiotics are still an expression of expert opinion not always supported by experimental or clinical proof. A typical example is the recommendation of two divided doses of gentamicin for treatment of streptococcal endocarditis. Nevertheless, it is the author's opinion that the development of uncomplicated, easy to handle diagnostic and treatment regimens are justified in order to achieve better compliance with these recommendations.     

Rational approaches to the treatment of culture-negative infective endocarditis.

The microorganism responsible for infective endocarditis may not be grown on blood culture in as many as 25% of cases. While this is to be expected with such relatively uncommon organisms as Coxiella burnetti, in most cases failure to grow the organism is likely to be due to either a low concentration of bacteria in the blood or because antibiotics were given before blood was taken for culture. The antibiotic treatment of culture-negative cases should be based on the assumption that the organisms responsible are the same as those found in cases with positive cultures, covering the most likely possibilities in such different circumstances as spontaneous infections of natural valves, endocarditis following cardiac surgery, early and late prosthetic valve endocarditis and infections associated with intravenous drug abuse.     

感染性心内膜炎瓣膜损害的外科治疗

目的 总结56例感染性心内膜炎(IE)瓣膜损害的外科治疗经验.方法 56例IE患者均在体外循环下施行心内直视手术,其中左房室瓣置换24例.双瓣膜置换19例,主动脉瓣置换7例,右房室瓣成形3例,右房室瓣置换2例,Bentall手术1例;同期矫治合并其他心血管畸形8例.急诊手术占34%(19/56).结果 长期存活50例,心功能均为Ⅰ～Ⅱ级.早期死亡4例(7.2%).其中3例为低心排综合征,1例为人工瓣感染性心内膜炎;晚期死亡2例.结论 对IE,尤其是急性心衰伴进行性加重不能控制者,应在血流动力学及瓣膜条件恶化前积极采用手术治疗.     

先天性心脏病继发感染性心内膜炎的外科治疗

论 积极的外科手术、完善的围手术期处理是治疗CHD继发IE的重要手段.     

The role of glycopeptide antibiotics in the treatment of infective endocarditis.

There are several sets of guidelines for the treatment of infective endocarditis, reflecting the need for differing treatment in various countries and times. This review considers the need for differing treatment modalities and in particular the utility of the glycopeptide antibiotics vancomycin and teicoplanin. Specific recommendations are offered as to when to consider the use of glycopeptides, appropriate dosage, length of treatment course and whether to use monotherapy or combined therapy. Used judiciously, the glycopeptides give results as good as can be achieved with other antimicrobial agents without exceptional toxicity. The potential of teicoplanin for use in the outpatient treatment of infective endocarditis is considered.     

Management of infective endocarditis

Infective endocarditis, in which infection or infective vegetations develop on heart valves or other endocardial surfaces, causes considerable morbidity and mortality. Prompt diagnosis and treatment can improve outcome and are therefore essential. Here, we discuss the management of infective endocarditis, concentrating on adult patients.     

Treatment and prevention of infective endocarditis

The paper presents the most recent recommendations for the treatment and prevention of infective endocarditis (IE). The treatment of IE is complex and requires close collaboration among specialists in infectious diseases, cardiology, cardiac surgery and microbiology. The mainstay of medical treatment is antibiotic therapy. Theoretical considerations regarding vegetations and antibiotics have practical consequences on the route and modalities of administration of antibiotics and on the techniques used to monitor treatment. The choice of antibiotics depends on the microorganism (streptococci, enterococci, staphylococci, HACEK group [Haemophilus sp., Actinobacillus sp., Cardiobacterium sp., Eikenella sp. and Kingella sp.], Coxiella, Brucella, Legionella, Bartonella, fungi) and on whether IE occurs on native or prosthetic valves. Treatment of IE with negative blood cultures is particularly difficult. Cardiac surgery is often needed during the bacteriologically active period (in ~ 50% of patients). The decision to intervene and the optimal timing of the intervention requires careful consideration of multiple potential risks: the haemodynamic risk, the infectious risk, the risk due to cardiac lesions, the risk due to extracardiac complications and the risk due to the location of infective endocarditis. Even though the efficacy of antibiotic prophylaxis of IE is not completely proven, it is recommended for selected patients who undergo an at-risk procedure. Lists of cardiac conditions and of medical procedures at risk are presented; specific antibiotic prophylactic regimens for dental and upper respiratory tract procedures in out-patients, procedures under general anaesthesia and urological and GI procedures are outlined.     

二尖瓣成形术治疗感染性心内膜炎合并二尖瓣关闭不全的临床观察

目的 观察二尖瓣成形术治疗感染性心内膜炎合并二尖瓣关闭不全的临床效果.方法 对本院2011年12月～2013年2月收治的106例感染性心内膜炎合并二尖瓣关闭不全患者进行研究,随机分为观察组（53例）与对照组（53例）,观察组患者采用二尖瓣成形术进行治疗,对照组患者采用二尖瓣置换术进行治疗,对两组患者的临床治疗效果及重症监护室（ICU）住院时间进行对比分析.结果 两组患者围术期均未出现死亡病例,两组患者术后心功能恢复情况差异无统计学意义（P＞0.05）;两组患者ICU住院时间差异有统计学意义（P＜0.05）.结论 采用二尖瓣成形术治疗感染性心内膜炎合并二尖瓣关闭不全的临床效果显著,患者康复较快.     

Treatment and prevention of infective endocarditis

The paper presents the most recent recommendations for the treatment and prevention of infective endocarditis (IE). The treatment of IE is complex and requires close collaboration among specialists in infectious diseases, cardiology, cardiac surgery and microbiology. The mainstay of medical treatment is antibiotic therapy. Theoretical considerations regarding vegetations and antibiotics have practical consequences on the route and modalities of administration of antibiotics and on the techniques used to monitor treatment. The choice of antibiotics depends on the microorganism (streptococci, enterococci, staphylococci, HACEK group [Haemophilus sp., Actinobacillus sp., Cardiobacterium sp., Eikenella sp. and Kingella sp.], Coxiella, Brucella, Legionella, Bartonella, fungi) and on whether IE occurs on native or prosthetic valves. Treatment of IE with negative blood cultures is particularly difficult. Cardiac surgery is often needed during the bacteriologically active period (in ~50% of patients). The decision to intervene and the optimal timing of the intervention requires careful consideration of multiple potential risks: the haemodynamic risk, the infectious risk, the risk due to cardiac lesions, the risk due to extracardiac complications and the risk due to the location of infective endocarditis. Even though the efficacy of antibiotic prophylaxis of IE is not completely proven, it is recommended for selected patients who undergo an at-risk procedure. Lists of cardiac conditions and of medical procedures at risk are presented; specific antibiotic prophylactic regimens for dental and upper respiratory tract procedures in out-patients, procedures under general anaesthesia and urological and GI procedures are outlined.     

38例感染性心内膜炎的临床分析

目的总结感染性心内膜炎38例的诊断、手术时机和疗效。方法回顾分析2002年1月～2008年12月接受手术治疗的感染性心内膜炎38例,其中先天陛心脏病11例（28．9％）,风湿性心脏病12例（31．6％）,退行胜变6例（15．8％）,无基础病变者9例（23．7％）,所有病人经外科手术清除感染病灶,纠治瓣膜病变及心脏畸形,术前进行血培养和彩色超声心动图检查。结果外科手术治疗前,超声心动图发现心脏及大血管赘生物32例（84．2％）,血培养阳性17例（44．7％）。手术后死亡2例（5．2％）。结论感染性心内膜炎早期诊断,适时手术和内、外科联合治疗是治疗成功的关键。     

感染性心内膜炎61例临床分析

目的了解笔者所在医院感染性心内膜炎的临床特点、病原菌及药敏情况,以指导临床治疗。方法回顾性分析笔者所在医院61例感染性心内膜炎患者的临床资料。结果 61例患者均有心脏基础疾病,其中先天性心脏病18例(29.51%),冠状动脉粥样硬化性心脏病、风湿性心瓣膜病各13例(各占21.31%),老年性心脏瓣膜病12例(19.67%),其他5例(占8.20%);人工瓣膜心内膜炎10例(16.39%)。发热、贫血和心功能不全为最常见的临床表现和首发症状。超声心动图检查发现心脏瓣膜病变51例(83.61%),最常见部位依次为二尖瓣、三尖瓣、主动脉瓣、肺动脉瓣;发现赘生物39例(63.93%),单一瓣膜受累的赘生物好发部位依次为二尖瓣(14例),主动脉瓣(13例);多个瓣膜同时受累中以二尖瓣和主动脉瓣最常见,有3例。61例血细菌培养阳性率为39.34%(24/61),其中革兰阳性细菌占绝对优势为83.33%(20/24),链球菌仍为主要致病菌。经验性抗菌治疗中,抗阴性菌为主者40例(65.57%),抗阳性菌为主者14例(22.95%)。本病死亡率高达14.75%,心功能不全和严重感染为常见原因。结论感染性心内膜炎瓣膜或心脏病变多样,临床表现特异性差,应引起足够重视。及时完善相关特殊检查,早明诊断,减少误诊;初始抗菌治疗仍以抗阳性菌的杀菌剂为主,及时的手术治疗亦同样重要。     

亚急性感染性心内膜炎45例临床诊治分析

目的探讨关于亚急性感染性心内膜炎的临床诊治措施。方法回顾性分析本院2009～2011年收治的45例亚急性感染性心内膜炎患者的临床资料,所有患者均采用抗生素治疗,观察患者的治疗效果。结果所有患者经治疗后,显效34例（75.6%）,有效6例（13.3%）,无效5例（11.1%）,总有效率为88.9%。治疗无效的5例患者中,死亡3例,死亡率为6.7%,其中,2例死于严重感染,1例死于严重肺栓塞。结论亚急性感染性心内膜炎的临床诊断应根据功能检查及实验室检测结果 ,并结合临床症状体征,以提高诊断正确率,早期合理使用抗生素积极治疗,以提高治疗有效率,改善患者预后。     

手术治疗感染性心内膜炎35例临床分析

目的探讨感染性心内膜炎的临床特点、手术指征及手术要点。方法回顾性分析该院接受手术治疗的35例感染性心内膜炎患者的临床资料。结果围术期死亡1例(2.86%)。术后随访6个月至5.5年均无心内膜炎复发,33例心功能Ⅰ～Ⅱ级,1例心功能Ⅲ级。结论及时把握手术时机,对感染性心内膜炎患者进行外科手术治疗,能明显改善患者生活质量,降低死亡率及围术期并发症的发生,效果满意。     

Mesothelioma: Drug treatment and other interventions

Malignant mesothelioma was reported to be a tumor of the pleura for which there is no satisfactory treatment. It was also reported to be almost universally fatal, regardless of the stage of the tumor at the time of diagnosis. Due to the dismal prognosis for patients with this malignant disease, a new mode of treatment is desperately needed. Current drugs and other interventional modalities which include surgery, chemotherapy and radiation therapy are discussed below. However, in some patients none of these modalities are superior to absence of treatment. Discussed within this article are single agent and combined chemomodality therapy studies, target ligands, radiation-sensitizing and antiviral agents, multimodality and gene therapy, and chemoresistance.     

1例感染性心内膜炎患者的药学监护

1例33岁男性患者,因寒战高热1月余,右侧下肢疼痛1周入院。1月前外院诊断为感染性心内膜炎,血培养检出耐甲氧西林金黄色葡萄球菌。因再次发热入院,3次血培养和赘生物培养均为阴性。参考外院药敏结果,提出治疗方案为万古霉素+萘夫西林+利福平抗感染,未能有效控制病情,后行心脏二尖瓣置换术+赘生物摘除术。术后根据患者低热和肾功能异常情况调整抗感染方案,应用利奈唑胺3 d后患者出现发热和白细胞下降,经分析判断为利奈唑胺的不良反应,及时调整治疗方案选用万古霉素+头孢唑啉,不良反应消失。患者后续恢复情况良好,术后抗感染疗程6周已足够,并对患者进行出院教育,随访未发现感染复发。     

临床药师参与1例曲霉菌引起的感染性心内膜炎患者治疗的药学实践

临床药师全程参与1例曲霉菌引起感染性心内膜炎患者的抗感染治疗,协助医师制订联合抗曲霉方案并对患者实施药学监护.通过疗效监测及对伏立康唑血药浓度的动态监测,不断调整伏立康唑用量,使患者的感染得到有效控制,未再出现发热、脑出血,心脏赘生物较前缩小,同时避免了严重不良反应的发生,提高了患者用药的安全性及有效性.