Clinical Features of Right-sided Infective Endocarditis

METHODSSubjectsWeretrospectivelyinvestigatedpatientswithRIEadmittedinourhospitalfromJan１９８５toDec２０００．Totally１７casesofRIEpatientswereincluded，amongwhich１２male，５female，withageof５to５６（mean２２）yearsold．Allpatientswerediagnosedbasedoncl     

感染性心内膜炎的外科治疗

目的：探讨感染性心内膜炎（ＩＥ）的诊断及外科治疗。方法：我院从１９８６年１１月至１９９６年５月，外科治疗感染心内膜炎患者１６例，其中男性１２例，女性４例。手术方法：全麻低温体外循环急诊换瓣手术７例（主动脉瓣替换５例，主动脉瓣＋二尖瓣替换１例，主动脉瓣替换＋膜部心室间隔缺损涤沦补片修补１例）；择期换瓣手术９例（主动脉瓣替换７例，二尖瓣替换２例）。切除瓣周感染组织，对散在于心室间隔和腱索上难以切除的微小赘生物电灼，术毕抗生素溶液冲洗心腔。结果：全组１６例。急诊手术７例，其中术后死亡１例（死亡率１４．３％），死亡原因为多器官衰竭；择期手术９例，无手术死亡。结论：反复多次血培养结合超声心动图检查，可使ＩＥ诊断阳性率大大提高。尽早手术是对部分ＩＥ患者治疗的基本原则，无法控制的感染和心力衰竭是尽早手术治疗的最佳适应证。     

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.     

Pseudoaneurysm Formation in Infective Endocarditis

Left ventricular pseudoaneurysms that develop in the setting of infective endocarditis are believed to result from remodeling of extravalvular abscesses. The high pressure generated by the left ventricle is thought to dissect into the abscess causing it to form a characteristic sac‐like protuberance readily recognized echocardiographically. Left ventricular pseudoaneurysms most often arise from abscesses in the mitral‐aortic intervalvular fibrosa and protrude external to the aorta. Less often, as described herein, they arise from abscesses external the posterior mitral annulus and project into the posterior interventricular groove. Perforation may result in camo‐cameral or aorto‐cameral fistula formation, as well as fistulous communication with the pericardial space.     

感染性心内膜炎的血培养阳性与阴性临床意义

目的　明确血培养阳性与阴性的感染性心内膜炎 (IE)之间在临床特征和预后方面的异同。方法　对63例IE患者 ,根据血培养结果分成阳性组 (N =15 )和阴性组 (N =48) ,比较临床特征和预后。结果　 41例 ( 65 .1% )经超声心动图检出有赘生物 ,两组病人的赘生物检出率、基础心脏病和感染部位一致 ,从入院到确诊时间无显著差异。两组病人入院前有使用抗生素的比率分别为 3 3 .3 %和 85 .4% (P <0 .0 1)。血培养阳性组白细胞计数较阴性组高 (P <0 .0 1) ,因而更易出现发热和脓肿并发症 (P <0 .0 5 ) ,而血培养阴性组更多出现心瓣膜破裂或穿孔 ,严重心衰 ,更多病人施行了心脏换瓣手术 (P <0 .0 5 ) ,但两组病人预后无统计学差异。结论　由于血培养前抗生素的广泛使用 ,IE血培养阳性率明显下降 ,超声心动图检查有助于血培养阴性IE的早期诊断。血培养阴性IE后果更为严重 ,早期诊断和及时的手术换瓣治疗可以改善预后     

感染性心内膜炎危险分层及预后预测研究进展

感染性心内膜炎有着高患病率和死亡率,早期识别高危患者并预测预后具有重要意义。近年来,越来越多的研究揭示了与其预后相关的预测因素。其中主要预后预测因素包括患者特征、临床并发症、病原微生物和超声心动图表现;新型预后预测因素包括炎症标志物水平、血小板减少症、中性粒细胞微囊泡水平、心脏瓣膜¹⁸F-氟代脱氧葡萄糖摄取强度。一些研究构建出具有重要临床价值的预后预测模型,如Hasbun R模型、Sy RW模型和Park LP模型。现从以上三个方面对感染性心内膜炎危险分层及预后预测的最新进展进行综述。     

感染性心内膜炎中国诊断标准的讨论

目的分析感染性心内膜炎的临床特征,比较研究国内、国际诊断标准.方法对1989年至2002年经我院病理科诊断证实的93例感染性心内膜炎患者进行临床特征分析,并以此为依据比较两种诊断标准的敏感性.结果连续2次或2次以上血培养阳性,且为相同致病菌的有20例,血培养阳性1次的有8例.超声心动图明确发现赘生物71例,脓肿3例,人工瓣膜部分开裂3例.发现主要血管征象25例.新出现反流杂音或杂音加重28例.中国标准的敏感性为76%,Duke标准敏感性为43%(P＜0.001).结论中国标准敏感性明显高于Duke标准,但仍需进行更多临床研究,特别是有关特异性临床研究.     

起搏器心内膜炎的外科治疗

目的　介绍 15例起搏器心内膜炎外科治疗的临床经验 ,讨论手术指征和时机。方法　1993年至 2 0 0 1年间 ,我们为 15例起搏器心内膜炎患者 ,施行了体外循环直视下心内起搏电极撤除术。本文对这些病人的临床资料进行回顾性研究。结果　本组病例中 ,有 2例院内死亡 ,术后随访期内 (中间值 =31 3个月 ;区间 ,1 8～ 5 8 7个月 )无远期死亡 ,总死亡率为 13 3%。所有出院病人均无感染复发。大部分病人心功能明显改善 (P <0 0 1)。只有 6例患者术后因持续存在的心律失常需要重新安装起搏器。本组病例中常见的外科手术指征为 :1)附着于起搏电极的大型赘生物 ,2 )顽固感染 ,3)三尖瓣架构损坏 ,4)肺栓塞 ,5 )存在需要外科处理的基础的或并存的心脏病变。结论　根据我们的结果及相关文献报道 ,我们认为对患起搏器心内膜炎的病人 ,应尽早采用外科手术撤除植入的心内起搏器硬件。手术治疗的远期效果是值得信赖的。     

Role of Surgery in Infective Endocarditis

ABSTRACT. One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (<60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71 % early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.     

感染性主动脉瓣心内膜炎的外科治疗

目的：报告感染性主动脉瓣心内膜炎的外科治疗经验。方法：７６例感染性主动脉瓣心内膜炎患者，男５８例，女１８例，平均年龄３７．８±１１．３（１２～６０）岁。其中动脉血培养阳性４１例，阴性３５例。２７例（急性活动期）因急性心力衰竭或严重败血症等并发症而急症手术，４９例（慢性静止期）在抗生素治疗６周后择期手术。本组７６例患者行主动脉瓣替换术７４例；应用带瓣管道行主动脉根部、主动脉瓣替换和冠状动脉移植术２例。同期处理动脉导管未闭３例、佛氏窦瘤破裂＋心室间隔缺损６例、心室间隔缺损３例、二尖瓣关闭不全１１例和三尖瓣关闭不全５例。结果：７６例患者术后早期死亡５例（６．６％）：急性活动期２例，慢性静止期３例。术后平均随访４．１５年（１０个月～１０年），晚期死亡４例，其中２例死于人工瓣膜性心内膜炎。结论：感染性主动脉瓣心内膜炎手术时机的掌握对治疗效果至关重要，急症手术并不增加手术死亡率。     

Infective Endocarditis: A Lethal Disease

Abstract: One-hundred-and-eighty-nine episodes of Infective Endocarditis were seen in 177 patients in the Green Lane Cardiology Unit over an 18-year period. Hospital survival was 79% and 13-year actuarial survival was 47%. A number of factors including the underlying cardiac lesion, infecting organism, clinical features and surgical intervention were related to outcome .
No patient with extreme heart failure survived without operation. Hospital survival in patients with severe heart failure was 69% (9/13 patients) where surgery was carried out before completion of antibiotic treatment, and 40% (6/15 patients) where the antibiotic course was completed. Survival was 53% in patients who still had a fever after one week of antibiotic treatment and 96% if the temperature was normal. In 61% of patients with a fever at one week, extended infected pannus was present compared with 6–10% where the temperature was normal. In patients undergoing operation before completion of antibiotics, the surgical mortality was higher but neither the incidence of recurrence of endocarditis nor the need for re-operation was increased .
We believe that better results will be achieved with a policy of surgical intervention when signs of infection and heart failure have not settled within one week of treatment .     

毒瘾者感染性心内膜炎的临床特征分析

为探讨毒瘾患者感染性心内膜炎的临床特征,本文对毒瘾组（８例）和非毒瘾组（２１例）感染性心内膜炎的临床表现和超声特征进行了对比分析。结果显示,毒瘾组金黄色葡萄球菌为主要致病菌,其阳性检出率（６２５％）较非毒瘾组（１９％）明显增高（Ｐ＜００１）;毒瘾组发热体温３９７±０４°Ｃ,较非毒瘾组３８５±０７°Ｃ高（Ｐ＜００５）,且多伴寒颤、肌肉酸痛;肺栓塞发生率毒瘾组（６２５％,５／８）高于非毒瘾组（４７％,１／２１）（Ｐ＜００１）,而外周栓塞发生率毒瘾组（１２５％,１／８）低于非毒瘾组（４２９％,９／２１）（Ｐ＜００１）;超声发现毒瘾组心腔赘生物检出６例（７５０％）,均位于右侧心腔,而非毒瘾组检出１５例（７１４％）,主要位于左侧心腔,毒瘾组赘生物较大,最大长度２２±０８（１２～３４）ｃｍ,非毒瘾组只有０９±０３（０５～１５）ｃｍ（Ｐ＜００１）。     

青少年及成人先天性心脏病感染性心内膜炎的临床研究

感染性心内膜炎占青少年及成人先天性心脏病科住院人数的４～５％。本文研究了１７７例（１３～７４岁，平均年龄２６岁：男：女为１．５：１）２０５次感染性心内膜炎，以确定受感染之先天性心脏缺损之种类，诊断的延误，死亡率及外科治疗对预后的影响。１４９次心内膜炎发生在根治性心脏手术之前（组１），其中２１例病人接受过减状治疗：５６次发生在手术根治后病人（组２）。最常见受累的缺损为主动脉瓣疾患（４３次），小室间隔缺损（４１次）和法乐氏四联症（２４次）。牙科检治，手术中及延长的围术期治疗以及皮肤创伤感染是最常见的诱发因素，有明确细菌学培养结果者１３９人次，其中最常见的为草绿色链球菌，在组１为５５％，组２为４９％；金黄色葡萄球菌感染组２（２５％）比组１（１３％）高。诊断延误时间在组１明显长于组２。在感染活动期特别是金黄色葡萄球菌感染时外科紧急手术治疗有时是必须的。手术根治后的先天性心脏病患者凡遗留有任何血流动力学改变者都需要预防感染性心内膜炎（包括换瓣病人）。     

Optimal Timing for Cardiac Surgery in Infective Endocarditis: Is Earlier Better?

All patients with infective endocarditis should be transferred to a hospital with cardiac surgery facilities. Once the decision to operate on a patient with infective endocarditis has been made, the timing of surgery is very often a difficult decision. Literature on this topic is very scarce. The European Society of Cardiology guidelines include recommendations on the timing of surgery. Heart failure, uncontrolled infection and prevention of embolic risk are the three main indications for surgery. Most often, when the decision to operate has been made, there is no benefit and potentially harm in delaying surgery. If cardiac surgery is indicated after an ischemic stroke, it should not be delayed. Discussion should be multidisciplinary and involve at least a cardiologist, a cardiac surgeon and an infectious diseases specialist, and any other specialist as needed (for example a neurologist).