血培养阴性感染性心内膜炎的临床诊断及外科治疗

目的 探讨血培养阴性感染性心内膜炎（IE）的临床诊断、外科手术时机选择和围手术期处理的策略。方法 回顾性分析2008年7月至2012年7月武汉亚洲心脏病医院收治的240例IE患者的临床资料，根据血培养结果分组，其中血培养阴性组158例，男88例、女70例，年龄（51.3±10.1） 岁；血培养阳性组82例，男45例、女37例，年龄（48.9±9.8） 岁。所有患者均行手术治疗，术中彻底清除赘生物、被破坏的瓣膜，切除瓣环邻近的坏死组织，同期行心瓣膜置换术或心内修补术。术后住ICU进行常规监护，给予强心、利尿、对症治疗，足量应用抗生素4～6周。结果 两组患者死亡4例，1例为低心排血量综合征、3例死于多器官功能衰竭，其中血培养阳性组死亡1例，血培养阴性组死亡3例，两组病死率差异无统计学意义（χ2=0.15，P=0.70）。其余患者均康复顺利出院；所有患者均进行随访6～36个月（中位随访时间22个月），其中2例死亡，1例于手术后2年死于脑梗塞，1例于术后3年死于脑出血。结论 血培养阴性IE炎患者应予广谱抗生素治疗，迅速控制病情，给予足够的量和时间，积极手术治疗，降低院内死亡率，改善患者生活质量和预后。

Clinical Diagnosis and Surgical Therapy for Blood Culture-Negative Infective Endocarditis

Objective To investigate clinical diagnosis，timing of surgery and perioperative therapeutic strategies for blood culture-negative infective endocarditis （IE）. Methods Clinical data of 240 IE patients who were admitted tWuhan Asia Heart Hospital between July 2008 and July 2012 were retrospectively analyzed. According to their blood cultureresults，all the patients were divided into blood culture-negative group and blood culture-positive group. In the blood culture-negative group，there were 158 patients including 88 male and 70 female patients with their age of 51.3±10.1 years. In the blood culture-positive group，there were 82 patients including 45 male and 37 female patients with their age of 48.9±9.8 years. All the patients underwent surgical treatment，and the surgical procedures included complete vegetations excision，debridement of infected valves，removal of necrotic tissue around the annulus，and concomitant heart valve replacement or intracardiac repair. Postoperatively，all the patients received routine monitoring in ICU，cardiac glycosides，diuretics，other symptomatic treatment and adequate dosages of antibiotics for 4-6 weeks. Results Four patients died postoperatively in this study including 1 patient for low cardiac output syndrome and 3 patients for multiple organ dysfunction syndrome，1 patient in the blood culture-positive group and 3 patients in the blood culture-negative group respectively. There was no statistical difference in surgical mortality between the 2 groups （χ2=0.15，P=0.70）. All the other patients were discharged successfully and followed up for 6 to 36 months with the median follow-up time of 22 months. During follow-up, 2 patients died including 1 patient for cerebral infarction 2 years after surgery and another patient for cerebral hemorrhage 3 yearsafter surgery. Conclusion Patients with blood culture-negative IE should receive adequate dosage and duration of broad-spectrum antibiotics to control the infection rapidly, and aggressive surgical therapy to decrease in-hospital mortality and improve their quality of life and prognosis.