感染性心内膜炎特点分析(附119例报告)

目的探讨感染性心内膜炎(IE)的基础病因、致病微生物、临床特征及治疗结果等因素,提高IE的诊治水平。方法对119例IE患者的基础病因、临床特征、致病微生物、治疗效果等临床资料进行回顾性分析。结果①基础病因中先天性心脏病比例最高(48例,40.3%),其次为风湿性心脏瓣膜病(36例,30.3%),无基础心脏病变有所增加(22例,18.5%)。②发热仍是IE最常见的临床表现(106例,89.1%)和首发症状(95例,79.8%),28例(23.5%)患者以心功能不全为主要症状。③98例患者做血培养,阳性率为63.1%(62例),其中链球菌27例(43.5%),葡萄球菌26例(41.9%)。④28例经胸超声心动图检查未发现赘生物的患者中11例(39.3%),手术发现赘生物,术后行病理检查均符合IE的病理诊断标准。结论基础病因中无基础心脏病变比例明显增加;葡萄球菌感染呈增多趋势。     

感染性心内膜炎67例分析

目的:探讨感染性心内膜炎(IE)的致病菌、临床特点.方法:回顾性分析67例IE的临床资料.结果:草绿色链球菌占36.8% ,金黄色葡萄球菌占31.6%.器质性心脏病59例占88.1%,其中风湿性心脏病22例(37.2%),包括人工瓣膜2例,先天性心脏病25例(42.3%).超声技术在心脏赘生物的检出率(83.5%)56例,阳性率远高于血培养.结论:随着抗生素的广泛使用和病原微生物的变化,IE的临床特征发生了显著变化,超声心动图检查和血培养有助于IE的诊断;基础心脏病是IE常见病因.     

小儿及少年感染性心内膜炎20例临床分析

目的 :为少儿感染性心内膜炎 (IE)的诊治及预防寻找对策。方法 :对 2 0例少儿 IE的临床资料进行回顾性分析。结果 :IE2 0例中 ,非青紫型先天性心脏病 1 0例 ,均为室间隔缺损 (VSD) ,其中 5例合并主动脉瓣关闭不全 (AI) ;青紫型先天性心脏病 2例 ;风湿性心脏病 6例 ;心脏结构正常 2例。部分患者伴有明显的免疫功能紊乱。血培养阳性 1 0例。超声心动图检查发现瓣膜赘生物1 7例。治疗主要用青霉素等。死亡 5例。结论 :1心脏结构异常是 IE的主要基础病因 ;2先天性心脏病 VSD合并 AI、风湿性心脏病有二尖瓣脱垂和联合病变者为发生 IE的高危儿 ,对这些患儿应定期用抗生素积极预防 ;3超声心动图检查对 IE的诊断有重要价值。4对确诊或高度疑诊的 IE患儿 ,首先应内科治疗。     

无基础心脏病的感染性心内膜炎患者25例临床分析

目的分析近5年18岁以下无基础心脏病的感染性心内膜炎(infective endocarditis,IE)患者的临床症状、实验室检查、病原学检查、超声心动图特点、并发症、手术治疗效果及预后,总结此类IE的治疗经验。方法回顾性分析广东省人民医院2010年1月至2015年10月住院的18岁以下无基础心脏病或其他易感因素的25例IE患者的临床表现、手术疗效及预后。结果共收集到25例,占18岁以下IE患者的22.12%(25例/113例),男13例,女12例,年龄10个月~18岁(中位年龄16岁),患者主要临床表现有发热(22例,88%),心脏杂音(23例,92%)。25例患者超声心动图检查均发现左心系统心内膜赘生物(100%),其中2例还合并有三尖瓣赘生物形成。并发症以心力衰竭最多(17例,68%),其次为栓塞事件(6例,24%)、脾肿大(2例,8%)。致病菌以链球菌属为主,其次为金黄色葡萄球菌。24例在内科积极抗感染治疗同时行外科手术清除赘生物并修复瓣膜,治愈23例(95.8%),其中1例因重度左心衰、术后低心排血量综合征死亡(4.16%);另1例因病程过长,全身多器官栓塞、功能受损而丧失手术机会死亡。结论对于无基础性心脏病的IE患者,发病率占22.12%,多伴有左心系统赘生物形成,造成心力衰竭,加重病情,应引起高度重视。对于有适应证的IE患者,尤其有左心系统赘生物形成及心力衰竭患者,在积极内科抗感染治疗的同时,应尽早手术,可获得良好预后。     

超声心动图在小儿感染性心内膜炎临床诊断中的应用价值

目的分析小儿感染性心内膜炎(IE)的临床特点,探讨超声心动图在IE诊断中的临床价值。方法选取我院2012年4月~2015年3月收治的IE患儿40例作为研究对象,分析IE的心脏基础疾病及临床表现,总结超声心动图特点。结果 IE患儿40例中,先天性心脏病22例,扩张性心肌病3例,心内膜弹力纤维增生症4例,风湿性心脏病6例,无基础性心脏病5例。超声心动图检查,伴有赘生物36例,阳性率为90%。患儿多以发热为首发症状,同时伴有心功能不全8例,脾肿大12例,镜下血尿10例。结论先天性心脏病是小儿感染性心内膜炎最常见的基础心脏病,超声心动图检查有助于IE的临床诊断,具有重要的临床价值。     

感染性心内膜炎13例临床分析

目的提高对感染性心内膜炎（IE）的诊治水平。方法回顾性分析13例IE的临床表现形式与治疗的关系。结果发热为常见及起始症状，贫血、脾大、心脏杂音及杂音改变，消瘦厌食、出汗、周围动脉栓塞。血培养阳性率61．54％，经胸超声心动图发现赘生物61．54％。结论①心脏结构异常是IE的主要基础病因；②先天性心脏病、退行性心脏瓣膜病、风湿性心脏病联合病变者为发生IE的高危人群；③超声心动图对IE的诊断有重要价值。     

802例感染性心内膜炎主要基础病因及病原学分析

目的:探讨感染性心内膜炎(IE)患者的主要基础病因及病原菌分布的特点。方法:针对中国医学科学院阜外医院2011年1月至2018年12月住院治疗的802例IE患者的基础病因和致病病原体进行回顾性分析,并分析IE患者的平均年龄、血培养和赘生物培养的阳性率及其变化趋势。结果:近8年IE患者平均年龄由2011年的40.3岁增至2018年的46.8岁,总平均年龄为42.8岁,男女患者比为3.18:1。其中,非风湿性心脏瓣膜病基础上发生的IE共410例(51.12%);在先天性心脏病基础上发生的IE共208例(25.94%);风湿性心脏瓣膜病基础上发生的IE共101例(12.59%);在心脏外科手术及介入治疗术后发生的IE共70例(8.73%)。802例IE患者共送检了535例血培养,阳性156例(29.16%);共送检576份瓣膜赘生物培养,102例(17.71%)培养阳性。156例IE患者血培养的主要分离菌为链球菌,共98例(62.82%);其次为葡萄球菌38例(24.36%)和肠球菌10例(6.41%)。IE患者瓣膜赘生物培养的主要分离菌为链球菌和葡萄球菌,分别有34例(33.33%)和33例(32.35%)。血培养中链球菌对青霉素的耐药率为3.10%,对万古霉素的耐药率为0%。结论:近8年IE患者的平均年龄增高。IE的基础心脏疾病中,风湿性心脏病减少,先天性心脏病相对增加,非风湿性心脏瓣膜病已成为IE最常见的基础心脏疾病。其主要病原菌仍以草绿色链球菌为主。     

阜外医院感染性心内膜炎300例临床特征分析

目的:分析近4年阜外医院感染性心内膜炎患者的临床、病原微生物特点、治疗及预后,提高该疾病的临床诊疗水平。方法:回顾性分析阜外医院2013年至2016年300例住院治疗的感染性心内膜炎患者的临床资料,着重分析其基础病因、致病微生物分布及临床转归情况。并对单纯药物治疗与手术治疗的临床及流行病学特点进行对比和分析。结果:300例患者平均年龄(40.0±15.7)岁。基础病因中先天性心脏病所占比例最高,106例(35.3%),其次为非风湿性心脏瓣膜病67例(22.3%)和心脏手术及介入治疗术后31例(10.3%),风湿性心脏病仅13例(4.3%)。临床表现最常见为心脏杂音280例(93.3%)和发热253例(84.3%)。并发症最常见的是心力衰竭226例(75.3%),其次为栓塞并发症50例(16.7%)。血培养阳性118例,阳性率为52.4%,其中链球菌仍然是最常见的致病菌,90例(76.3%),其次为葡萄球菌, 13例(11.0%)。300例患者中有274例(91.3%)有阳性发现(赘生物、瓣膜穿孔、脓肿、人工瓣瓣周漏等),237例手术或病理所见与超声心动图符合。住院病死率为3.0%。外科治疗治愈好转率明显高于内科治疗(96.6%vs 48.6%,P0.001)。结论:感染性心内膜炎患者基础心脏病因最常见的是先天性心脏病。链球菌依然是感染性心内膜炎最常见的致病菌。感染性心内膜炎血培养阳性率低,超声心动图阳性表现成为最为重要的诊断依据。早期、有效、规律的抗菌药物治疗仍是治疗基础,及时的外科治疗可降低病死率。     

先天性心脏病感染性心内膜炎超声心动图与手术结果对照研究

目的　分析 2 1例先天性心脏病感染心内膜炎 ( IE)的临床资料、超声心动图术前诊断和手术后结果 ,为其诊断及治疗提供参考。方法　对比研究本组各类先天性心脏病 IE的并发率、临床特点、血培养、心电图、术前超声心动图诊断结果及术后心内膜受损的情况。结果　本组先天性心脏病 IE患者室间隔缺损及主动脉瓣病变的发病率最高。手术证实心内膜受损部位以主动脉瓣受累最多 ,也可有多个瓣膜及多种病变的损坏。结论　先天性心脏病的早期诊断治疗是减少 IE发生的重要预防措施 ,赘生物侵犯主动脉瓣的机率高于二尖瓣。超声心动图诊断结合临床 ,反复多次检查是早期诊断的关键。     

超声心动图对感染性心内膜炎的诊断价值分析

目的分析超声心动图对感染性心内膜炎(IE)的诊断价值。方法选取内蒙古医科大学附属医院2015年3月—2016年3月收治的IE患者89例,均进行超声心动图检测,观察瓣膜受累情况、赘生物附着部位并测量其大小。结果血培养阳性患者30例(33.7%),其中革兰阴性杆菌9例,革兰阳性球菌21例。经超声心动图检查发现心脏瓣膜赘生物形成患者85例(95.5%),其中主动脉瓣30例、左房室瓣21例、主动脉瓣和左房室瓣13例、右房室瓣11例、肺动脉瓣10例;赘生物直径10 mm者45例、11~15 mm者33例、16~20 mm者5例、21 mm者2例。结论超声心动图检查能能快速发现并准确定位IE患者心脏瓣膜赘生物,诊断价值良好。     

感染性心内膜炎120例临床分析

目的 探讨感染性心内膜炎(IE)的基础病因、致病微牛物和临床特征,提高IE的诊治水平.方法 回顾件分析北京协和医院1997年10月-2007年9月确诊的120例IE患者的临床资料.结果 120例IE患者中,108例(90.0%)为自然瓣膜心内膜炎(NVE),12例(10.0%)为人工瓣膜心内膜炎(PVE);29例(24.2%)无基础心脏病变,79例(73.1%)NVE患者存在各种基础心脏病,其中先天性心血管畸形30例(38.0%),其次为特发性二尖瓣脱垂(23例,29.1%)和风湿性心脏病(11例,13.9%).临床主要表现为发热(100.0%)、贫血(65例,54.2%)和栓塞(58例,48.3%).有83例(69.2%)细菌培养阳性,其中43例(51.8%)致病菌为链球菌.结论 IE最常见的基础心脏病前3位是先天性心血管畸形、二尖瓣脱垂和风湿性心脏病.不明原因长期发热患者应想到心内膜炎?鬃 的町能,血培养和超声心动图检查有助于IE的诊断.     

感染性心内膜炎应用人工瓣膜和自体瓣膜的病原菌及赘生物附着的临床分析

目的:研究感染性心内膜炎(IE)的临床特点及病原菌的变迁,比较人工瓣膜心内膜炎(PVE)及自体瓣膜心内膜炎(NVE)在致病微生物及赘生物附着部位方面的特点.方法:检索我院2003-05到2008-05符合Duke标准的266例住院治疗的IE患者,进行回顾性分析,并分为PVE(n=37)及NVE(n=229)两组进行比较.结果:91.4%(243/266)的IE患者存在基础心脏疾病,包括先天性心脏病101例,非风湿性瓣膜病77例,风湿性心脏病62例,肥厚型梗阻性心肌病3例.82.0%(218/266)发现赘生物,常见附着部位依次为主动脉瓣、二尖瓣、主动脉瓣合并二尖瓣.血培养阳性率49.5%(103/208).致病菌中革兰氏阴性杆菌及真菌呈增长趋势.PVE组常见致病菌依次为革兰氏阴性杆菌,葡萄球菌及真菌;NVE组为链球菌,葡萄球菌及革兰氏阴性杆菌.PVE组与NVE组相比赘生物检出率低(P<0.01),但血培养阳性率高(P<0.01).链球菌、凝固酶阴性葡萄球菌及革兰氏阴性杆菌,在两组培养致病菌间差异有统计学意义(P<0.05).早期和晚期PVE细菌谱不同.PVE组的住院总病死率高于NVE组.结论:IE患者的疾病谱及致病菌与既往报道相比均有较明显改变,PVE与NVE常见致病菌及赘生物检出率不同,应及时行血培养及经食管超声心动图检查,根据药物敏感试验结果应用有效的抗生素,同时应积极预防医源性感染.     

感染性心内膜炎70例临床分析

目的 探讨感染性心内膜炎(IE)的临床特点、治疗方法及转归。方法 回顾分析北京协和医院自1988年1月～2000年5月间确诊的70例IE临床特点。结果 (1)8例(11．4％)为人工瓣膜心内膜炎(PVE),62例(88．6％)为自然瓣膜心内膜炎(NVE);57例(91．9％)NVE病人存在各种基础心脏病,其中先天性心血管畸形(22例,38．6％)最常见,其次为特发性二尖瓣脱垂(18例,31．6％)和风湿性心脏病(12例,21．1％)。(2)临床主要表现为发热(100％)、贫血(40例,57．1％)和栓塞(33例,47．1％)。(3)60％(42例)病例细菌培养阳性,23例致病菌为链球菌。(4)39／51例IE经过单纯抗感染治疗痊愈,17／19例经过抗感染治疗联合外科手术治愈。死亡14例,其中包括5例PVE和2例起搏器植入术后IE;顽固性充血性心力衰竭是最常见的死亡原因(9／14)。结论 IE最常见的基础心脏病前3位是先天性心血管畸形、二尖瓣脱垂和风湿性心脏病。不明原因长期发热患者应想到心内膜炎的可能,血培养和超声心动图检查有助于IE的诊断。PVE、起搏器植入术后合并IE以及并发顽固性充血性心力衰竭则预后不良。     

Valve replacement in patients with active infective endocarditis

Eleven of 138 patients with infective endocarditis (IE) who underwent cardiac valve replacement for IE during a 12 1/2-year period had active IE. Eight of the 11 (all with aortic IE) had positive blood cultures within 48 hours preoperatively; six of the eight had positive Gram stains and cultures of the excised cardiac tissue. All 11 patients had Class IV cardiac functional disability (New York Heart Association classification) at the time of surgery. Staphylococci (three patients with Staphylococcus aureus and one with S. epidermidis) were the most frequent isolates. Three patients died; two of these three deaths occurred in patients who had a sudden onset preoperatively of severe aortic regurgitation and heart failure. In one patient (S. epidermidis infection) prosthetic valve endocarditis developed. Cardiac valve replacement may be performed successfully in patients with active IE even when blood cultures are positive in the immediate perioperative period. The hemodynamic status of patients with IE should be the determining factor in the timing of cardiac valve replacement, rather than the activity of the infection or the length of preoperative antimicrobial therapy. A radical surgical procedure may be necessary in patients with myocardial or aortic abscesses in whom conventional aortic valve replacement is not possible.     

Echocardiographic and clinical correlations in infectious endocarditis of the left heart

The echocardiographic features were correlated with the clinical findings and outcome in 35 patients with aortic and/or mitral valve endocarditis. There were 26 males and 9 females with a mean age of 38 years. The infection involved native valves in 27 patients and prosthetic valves in 8 patients. Echocardiographically, fourteen patients had involvement of native aortic valve. All patients in this group required surgical intervention, nine patients during antimicrobial therapy. Congestive heart failure was the clinical indication for valvular replacement. A patient died immediately after surgery from low cardiac output syndrome. Six patients had echocardiographic evidence of aortic and mitral valves involvement. A patient in this group expired before surgery, five underwent surgery because of progressive heart failure (aortic or aortic and mitral valves replacement). Seven patients showed lesions on native mitral valve (6 in this group had prolapse syndrome). A patient died from cerebrovascular embolus, two underwent surgery because of persistent infection and embolic events, four were successfully treated with medical therapy. Among patients with prosthetic valve endocarditis, four showed signs of valvular dehiscence and required surgical intervention, during antimicrobial therapy, from congestive heart failure; one patient expired from recurrent infection. The pathological findings correlated well with echocardiographic findings. Conclusions: in IE the localization of lesions by echo has prognostic significance: most patients with aortic valve or aortic and mitral valves endocarditis require early surgical intervention because of congestive heart failure. On the contrary, mitral valve involvement carries a better prognosis, requiring less frequently valvular replacement; the patients with echocardiographic signs of prosthetic valve dehiscence require urgent intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical aspects of endocarditis

Endocarditis represents a difficult medical problem that must occasionally be treated surgically. Constitutional symptoms of infection are important and are usually the reason that the patient seeks medical attention. Fever is the most common sign of infective endocarditis and a heart murmur, which changes in character or is new, is a significant hallmark. The diagnosis for infective endocarditis is made by high index of suspicion in a patient with valvular heart disease or a prosthetic heart valve and in the presence of fever and a cardiac murmur. A positive blood culture is the hallmark of the diagnosis. The absolute indications for operative intervention are congestive heart failure, unstable prosthetic valve, uncontrolled infection, and relapse after optimal therapy (prosthetic valve). Relative indications for operative intervention are perivalvular extension of the infection, staphylococcal infection of a prosthesis, persistent fever (culture negative), large vegetation, or relapse after optimal therapy (native valve). The principles of surgical management are to remove all infected tissue by thorough debridement back to normal tissue. This is combined with replacement of damaged valves and repair of associated defects. The mortality after operation for infective endocarditis is 15-20%. Late survival after operation for infective endocarditis on a native heart valve is 70-80% at 5 years. Survival falls to 50-80% at 5 years for surgery on an infected prosthetic heart valve.     

215例感染性心内膜炎临床分析

目的探讨感染性心内膜炎的临床特征,提高感染性心内膜炎的诊治水平.方法回顾性分析了215例感染性心内膜炎的基础病因、临床表现及并发症等.结果感染性心内膜炎基础病因中风湿性心脏病比例(30.2%)有所下降,而先天性心脏病比例(34.9%)相对升高,无基础心脏病比例(16.7%)比以往报道明显增加.发热(占87.9%)为感染性心内膜炎常见临床表现及首发症状,其次是贫血(61.9%)及脏器栓塞(21.9%).血培养阳性率为57.7%,其中主要致病菌是草绿色链球菌(32.4%)和表皮葡萄球菌(15.5%).134例(62.3%)超声心动图检查发现赘生物.17例早期人工瓣膜心内膜炎有8例死亡,占47.1%.住院期间死亡率为10.6%,死亡原因主要是心力衰竭和脑血管意外.结论感染性心内膜炎基础病因和致病菌发生较明显变化,早期人工瓣膜心内膜炎死亡率高,应尽早手术治疗.     

再次心脏瓣膜手术285例临床分析

目的:总结再次心脏瓣膜置换手术的病因及诊疗体会。方法:回顾分析自2007年3月至2013年10月,在第三军医大学新桥医院施行心脏瓣膜再次手术的285例患者的临床资料。其中男性92例(32.3%),女性193例(67.7%),年龄2~72岁,收集患者术前合并症,术前心功能状态,初次手术方式,再次手术的原因及手术方式,围手术期死亡情况等相关临床资料,通过多因素Logistic回归分析再次心脏瓣膜病围手术期死亡的相关危险因素。结果:本组患者再次手术的原因为二尖瓣闭式扩张术后再狭窄、生物瓣毁损、机械瓣功能障碍或其他病因;全组围手术期死亡18例,病死率6.31%,主要原因为低心排出量综合征(低心排),恶性心律失常,呼吸衰竭,心力衰竭,多器官衰竭。多因素Logistic回归分析结果显示,患者术前合并其他系统疾病(OR=3.530,P=0.049),术前心功能IV级(OR=4.025,P=0.025),术中主动脉阻断时间120min(OR=5.748,P=0.004),术后呼吸机支持时间24h(OR=4.770,P=0.025),是患者围手术期死亡的独立危险因素。结论:再次心脏瓣膜手术难度大,手术风险较高,准确的把握手术时机,术中注意心肌的保护,术后加强心肺肾等重要器官的监护和处理,再次心脏瓣膜手术有较高的手术成功率。术前合并其他系统疾病,术前心功能IV级,主动脉阻断时间较长是再次心脏瓣膜手术围手术期死亡的危险因素。     

Heart surgery in patients on chronic dialysis: is there still room for improvement in early and long-term outcome?

The purpose of this study was to review the outcome of dialysis-dependent patients undergoing cardiac surgery. We retrospectively reviewed 81 dialysis-dependent patients with a mean age of 62.5 ± 9.4 years who underwent cardiac operations. Mean EuroScore was 7.1 ± 3.9 (>9 in 18 patients). Surgery included coronary artery bypass grafting (CABG) in 43 patients (53.1%), valve surgery in 16 (19.7%), combined CABG plus valve surgery in 19 (23.5%) and major aortic surgery in three patients. In-hospital mortality rate was 13.6%. Most of the deaths occurred in patients who underwent valve procedures or combined surgery. Preoperative New York Heart Association class IV, previous acute myocardial infarction, combined surgical procedures, major aortic surgery, age >70 years, history of heart failure, female gender, the duration of dialysis ≥ 5 years and urgent/emergent surgery were associated with high relative risk for perioperative death. The actuarial survival was 72.2% at 5 years. Predictors of increased late mortality were heart failure, urgent/emergent surgery, the complexity of the surgical procedures (valve surgery, combined CABG + valve and major aortic surgery) and postoperative low cardiac output syndrome. In dialysis-dependent patients, CABG has an acceptable risk. Results in patients affected by valve lesions associated or not with coronary artery disease are improved by an early referral to surgery, before the onset of symptoms of heart failure.