静脉注射吸毒者感染性心内膜炎的外科治疗

目的 探讨静脉注射毒品所致感染性心内膜炎的外科治疗经验.方法 17例患者静脉注射毒品史2～10年,均有心脏瓣膜赘生物;其中三尖瓣赘生物并关闭不全16例,二尖瓣赘生物并关闭不全合并室间隔缺损1例,术前血培养阳性8例.三尖瓣置换术8例,三尖瓣成形术8例,二尖瓣置换同期室间隔缺损修补术1例.术后平均随访(44.7 ±19.1)月.结果 全部患者治愈出院,心功能明显改善,随访期间抗凝不当致大咯血1例,三尖瓣重度返流1例.结论 外科手术修复受累瓣膜或置换瓣膜是治疗静脉吸毒性感染性心内膜炎的有效手段.     

Surgical therapy in patients with active infective endocarditis: seven-year single centre experience in a subgroup of 255 patients treated with the Shelhigh stentless bioprosthesis

OBJECTIVE: We investigated outcomes after surgical therapy in patients with active infective endocarditis (AIE) with regard to survival in relation to surgical urgency, valve position, number of valves implanted and abscess formation. We aimed to identify independent risk factors for early mortality. METHODS AND RESULTS: Two hundred and fifty-five patients received Shelhigh bioprostheses between February 2000 and March 2007. A total of 74.1% had native and 25.9% prosthetic AIE. Surgery was regarded as urgent in 57.3% and as an emergency procedure in 38.4%. There was a highly significant difference in survival rate between patients who were operated on urgently versus in an emergency (p<0.0001), between single and double valve replacement (p=0.0206) and between patients with and without abscess formation (p=0.0245). There were two cases of early reinfection (0.78%) and six of late reinfection (2.35%) leading to re-operation. CONCLUSIONS: The survival of patients differs significantly in dependence on their surgical urgency. Better outcome could have been achieved if patients had been referred earlier for surgery and operated upon before heart failure or septic shock developed. Long-term survival was better in patients without abscess formation. The low reinfection rate of Shelhigh bioprostheses in AIE is promising and the early and mid-term results achieved need to be verified in the long-term course.     

活动期感染性自然心内膜炎的外科治疗

目的　总结活动期感染性自然心内膜炎外科治疗的经验。方法　自 1996年 10月 1日至 2003年 12月 31日,阜外心血管病医院外科共手术治疗活动期感染性自然心内膜炎 54例。有明确感染诱因的 21例,先天性心内结构畸形 23例,风湿性瓣膜病 1例。术前心功能NYHA分级:Ⅰ级6例,Ⅱ级 12例,Ⅲ级 7例,Ⅳ级 29例。术前左心室舒张末径 ( 63±11 )mm。发病至手术间隔 8 ~629d(中位数 125d)。行主动脉瓣置换 25例,主动脉瓣及二尖瓣置换 15例,二尖瓣置换 6例,二尖瓣成形 3例,肺动脉瓣置换 1例,单纯心内分流修补 4例。术后应用足量敏感抗生素 6 ~8周。结果手术死亡 5例,死因均为感染,术后即失访 4例,手术死亡率 17% (9 /54)。14例 ( 26% )发生手术并发症。45例随访 6~67个月,平均(31±19)个月。术后心功能NYHA分级Ⅰ级 41例,Ⅱ级 3例,Ⅲ级 1例,左心室舒张末径 (52±8)mm。2例病人接受再次手术,术后康复;有再次手术指征但未手术者 3例。术后晚期意外死亡 1例,抗凝过量致颅内出血 1例。结论　活动期感染性自然心内膜炎经积极的外科治疗能够取得较好的治疗效果。     

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective

We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.

Methods

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.     

Surgical treatment of acute infective valvular endocarditis (18 years experience)

BACKGROUND: Infective endocarditis morbidity remains high: 3 to 8 cases per 100,000 of population. Antibiotic therapy is ineffective. Its surgical treatment experience is relatively limited. Aim: To share the surgical treatment experience of 855 patients with acute infective valvular endocarditis (AIVE) treated during 1982 to 2000 in the Institute of Cardiovascular Surgery AMS, Ukraine. MATERIALS AND METHODS: 855 (75.4%) of 1128 hospitalized patients with AIVE were operated upon. Surgical interventions included removal of diseased tissues, heart chambers treatment with antiseptic solutions, wash out with normal saline solution, replacement or plastic procedure of valves. RESULTS: Heart abscesses were found in 132 (15.5%) patients. Hospital mortality was after aortic valve replacement 12.6%; mitral valve replacement 9.7%; plastic procedure on mitral valve 0%; aortic and mitral valve replacement 30%; tricuspid valve replacement 15.4%; and plastic procedure on tricuspid valve 6.1%. Recurrences of infective process occurred in 51 (6.0%) patients. Infections were observed more frequently in patients with heart abscesses: 10.6% versus 5.7% (p < 0.02). RESULTS: 716 (96.7%) patients were studied 2 to 194 (87.4+/-39.4) months postoperatively. Tenth year postoperative survival was 62.1+/-27.7% including hospital mortality. CONCLUSIONS: (1) AIVE has become one of the most frequent causes of acquired heart lesions in the postChernobyl nuclear power station catastrophe era. (2) Heart failure development in postoperative period is stipulated by the disease duration. (3) Presence of heart abscesses favors recurrence of development of infective endocarditis. (4) Postoperative antibiotic therapy for more than 3 weeks does not help in prevention of recurrences.     

Splenic abscess associated with active infective endocarditis

Splenic abscess is a rare complication in infective endocarditis. Here, we present two cases of splenic abscess associated with active infective endocarditis. Body computed tomography before emergency valvular surgery revealed abscess in the spleen. In case 1, the abscess was localized within the spleen; splenectomy and valve replacement were performed through the same median skin incision. In case 2, the splenic abscess was diagnosed as ruptured; valve replacement was performed, followed by splenectomy through a separate skin incision. No recurrence of infection occurred after surgery in either case. In surgical treatment for active infective endocarditis, body computed tomography is essential to diagnose splenic abscess preoperatively. If there is an abscess, then splenectomy and valvular surgery should be performed simultaneously to prevent reinfection after valvular surgery. The approach to the spleen should be individualized according to the extension of the abscess.     

Surgical progress: surgical management of infective endocarditis.

Infective endocarditis of bacterial or fungal origin may arise in either the left or the right heart and can involve both natural and prosthetic valves. The diagnosis is based primarily upon clinical criteria and positive blood cultures, but serial electrocardiograms, fluoroscopy, and two-dimensional echocardiograms may also be helpful. The initial treatment should consist of antibiotic therapy and is itself often adequate in effecting cure. However, careful observation during antibiotic treatment is mandatory, since the development of congestive heart failure due to valvular obstruction or destruction can be an indication for surgical intervention. Other surgical indications include a failure to respond to antibiotic therapy, pulmonary or systemic emboli, evidence of abscess involving the valvular ring (particularly prevalent with prosthetic valve endocarditis), Brucella infection, and the onset of conduction disturbances. The goals of surgical treatment are removal of infective tissue, restoration of valve function, and correction of associated mechanical disorders. The results are surprisingly good, especially for a condition of this severity.     

Favorable ten-year experience with valve procedures for active infective endocarditis

We have reviewed our 1972 to 1982 experience with valve procedures for infective endocarditis in 52 consecutive patients to evaluate the results of an interdisciplinary policy of early operation for uncontrolled complications. There were 47 patients with native valve endocarditis and five with prosthetic valve endocarditis. Twenty-seven were drug addicts and 25 were not. Thirty-seven (71%) required operation during the active phase of the disease and 15 during the inactive phase. Ninety-three percent of the addicts, 41% of the nonaddicts, and all patients with prosthetic valve endocarditis were in the active group. The distribution of infected valves was as follows: aortic, 21 active and 10 inactive; mitral, six active and three inactive; aortic and mitral, five active and two inactive; aortic and tricuspid, one active and none inactive; and tricuspid, four active and none inactive. Streptococcus was the most common infecting organism in both groups--predominantly group D in addicts and non-D in nonaddicts. Staphylococcus, gram-negative rods, and fungi occurred only in the active group. Indications for operation were congestive heart failure alone (19 active and 15 inactive), congestive heart failure and refractory infection or major emboli (nine active and none inactive), and resistant or refractory infection alone or with emboli (nine active and none inactive). Periannular abscess or aneurysm formation was most frequent at the aortic valve site in patients with native valve endocarditis; it occurred in 13 of 25 patients (52%) in the active group and in one of 12 patients (8%) in the inactive group. Six patients with preoperative stroke syndromes underwent operation without neurological deterioration; two patients had rupture of cerebral mycotic aneurysms postoperatively. Hospital mortality was 8% (3/7) in the active group and 0% in the inactive group. The late actuarial survival rate was 64% at 5 years and 54% at 10 years. Seven of nine deaths in the addict group were related to continued drug use, with five deaths occurring in the first 18 months. These results support a policy of early operation for uncontrolled complications with attention to the particular problems of active endocarditis.     

Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.     

An alternative surgical approach for aortic infective endocarditis: vegetectomy

We describe a case of successful vegetectomy of the aortic valves for early infective endocarditis. An aortic vegetectomy was performed as an alternative to valve replacement for a 54-year-old man with three vegetations and mild regurgitation in aortic valve due to infective endocarditis. Postoperative clinical course was without signs of recurrent infection after follow-up of 19 months, and transesophageal echocardiography demonstrated aortic valve competence. We would suggest that vegetectomy with valve sparing may be a viable option in the context of early infective endocarditis involved aortic valve in selected patients.     

Surgery for infective valve endocarditis in children

Objective: Surgery for endocarditis in children is relatively uncommon. Our aim is to assess operative mortality, recurrent infection, re-operation and long-term survival rates following surgery for infective valve endocarditis in children. Patients: Sixteen consecutive children (ten female, six male, mean age 11.8 years, range 25 days–16 years) undergoing surgery between 1972 and 1999 in Southampton were studied. The aortic valve was affected in five, mitral in four, aortic and mitral in one, tricuspid in five and a pulmonary homograft in one patient. Prosthetic valve endocarditis was present in three. Twelve surgical interventions were emergency and four urgent. Indications for operation included cardiac failure in five, severe valvular dysfunction in nine, vegetations in nine, persistent sepsis in four and embolization in four patients. The offending micro-organism was identified in 13. Valve replacement was performed in 11 and excision of vegetations in two and excision of vegetations and repair in three. Follow-up was complete (mean 11.2 years, range 2 months to 26.3 years, total 179.5 patient years). Results: There was one operative death (6.2%) in a 25-day-old neonate who presented in a moribund condition. Endocarditis recurred in one patient (6.25%). Freedom from recurrent infection at 10 and 20 years was 100.0 and 87.5%. Seven surgical re-interventions were required in four (25.0%) patients with no operative mortality. Freedom from re-operation at 1, 5, 10 and 20 years, was 84.6, 76.1, 76.1 and 60.9%, respectively. Two patients died 15 and 23 years after their first operation. The cause of the late deaths was non-cardiac in the first and unknown in the other. Actuarial survival, including operative mortality, at 1, 15 and 20 years was 93.7, 93.7 and 78.1%. Conclusions: Surgery in children with infective valve endocarditis can be performed with low operative mortality. Although some patients may require re-operation, freedom from recurrent infection and long-term survival are satisfactory.     

Surgical results of active infective native mitral valve endocarditis: repair versus replacement

Objective: The current study compared clinical outcomes after mitral valve repair or replacement in patients with active infective endocarditis involving only the native mitral valve. Methods: From January 1994 to December 2009, 102 patients were identified with active infective native mitral valve endocarditis. Mitral valve repair (MVP) was performed in 41 patients and mitral valve replacement (MVR) in 61 patients. The mean age was 34.4 ± 16.9 years in the MVP group and 43.1 ± 14.9 years in the MVR group (p = 0.007). The composite end points of cardiac death and cardiac-related morbidities were compared in these two groups using the inverse-probability-of-treatment-weighted method. The median follow-up time was 4.7 years (range, 0.1–15.8) and follow-up was possible in 100 (98%) patients. Results: There were three in-hospital deaths (2.9%), all in MVR patients (p = 0.272). The mean cardiopulmonary bypass time and aortic cross-clamping time were 111.4 ± 34.7 min and 72.7 ± 23.7 min in the MVP group and 101.1 ± 42.9 min and 62.9 ± 26.9 min in the MVR group (p = 0.204, p = 0.062). The 1-, 5-, and 10-year survival rates were 97.5%, 97.5%, and 81.1%, respectively, in the MVP group and 90%, 85.8%, and 85.8%, respectively, in the MVR group (p = 0.316). Actuarial event-free survival at 1, 5, and 10 years was 92.7%, 89.5%, and 72.2% in the MVP group, and 94.8%, 81.0%, and 77.3% in the MVR group (p = 0.787), respectively. Conclusions: The present study showed that postoperative long-term survival and event-free survival in patients with active infective endocarditis of the native mitral valve were not statistically significantly different regardless of whether patients underwent MVP or MVR.     

Surgical management of multivalvular heart disease

Background This study of patients with multivalvular lesions was undertaken to assess optimal surgical management and identify risk factors for prognosis. Methods Five hundred and twenty one patients underwent valve repair or replacement surgery between January’90 and December’98. Mean age was 30.19±12.2 years and 342 were males. All patients had dyspnoea on exertion, 467 (89.6%) were in New York Heart Association (NYHA) Class III and 47 (9.0%) were in Class IV. Congestive Heart Failure in 67 (12.3%) and prior cardiac procedure in 66 (12.2%) were other risk factors. The valves affected were mitral and aortic in 483 (Group 1), mitral and tricuspid in 43 (Group II) and mitral, aortic and tricuspid in 40 (Group III) patients. Surgical procedures included, several different combinations using repair or replacement with prosthetic or biological substitutes. Results Operative mortality was 9.8% (51 patients). Follow up (1 to 108 months, mean 45 months) was 94% complete. Late mortality occurred in 48 patients (10.4%). Causes included, left ventricular dysfunction (n=21), valve thrombosis (n=10) and, endocarditis (n=8). Freedom from late events was 50.7±8.5% at 9 years. At their last visit 40 patients were in Class IV, 18 were in Class III, 59 in Class II and the remaining in Class I (NYHA). Conclusions Important predictors of early mortality were NYHA Class IV, congestive heart failure, tricuspid valve disease and prior cardiac surgery. Left ventricular dysfunction was an important determinant of late outcome.     

Surgical versus medical treatment for infective endocarditis in patients on dialysis: a systematic review and meta-analysis

Infective endocarditis (IE) is a serious infection and causes significant morbidity and mortality. However, the benefit of surgery for endocarditis besides antibiotic treatment in dialysis patients remains controversial. We performed a systematic review of studies published between 1960 and February 2022. Meta-analysis was conducted with a random-effects model to explore the in-hospital, 30, 60, 90, 180-d, and 1-year mortality rates in adult dialysis patients with IE. Sensitivity analysis, subgroup analysis, and meta-regression were performed to explore potential sources of heterogeneity. Confidence of evidence was evaluated by the GRADE system. Thirteen studies were included. The pooled odds ratio of in-hospital mortality was 0.62 (95% confidence interval [CI]: 0.30–1.28, p = .17), with moderate heterogeneity (I² = 62%, p < .01). Three studies reported 30-d mortality, and the pooled odds ratio for surgery compared with medical treatment was even lower (0.36; 95% CI: 0.22–0.61, p < .01), with low heterogeneity (I² = 0%, p = .86). With studies on fewer than 30 patients excluded, the sensitivity analysis revealed a low odds ratio of in-hospital mortality for surgery versus medical treatment (0.52; 95% CI: 0.27–0.99, p = .047), with moderate heterogeneity (I² = 63%, p < .01). Subgroup analysis revealed no significant differences between any two comparator subgroups. Based on a very low strength of evidence, compared with medical treatment, surgical treatment for IE in patients on dialysis is not associated with lower in-hospital mortality. When studies on fewer than 30 patients were excluded, surgical treatment was associated with better survival.     

Double valve replacement for infective endocarditis in a hemodialysis patient: A case report

A 57-year-old man who was in end stage renal failure underwent an aortic and mitral valve replacement for the progression of cardiac dysfunction, secondary to Staphylococcus aureus infective endocarditis. Cardiac surgery was performed using a Hemo-Concentrator during cardiopulmonary bypass, 82 months following the initiation of hemodialysis. This is the second report in the literature of a successful double valve replacement for infective endocarditis and congestive heart failure in a chronic hemodialysis patient.     

Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.