Gamba Amando, Terzi Amedeo, Ferrazzi Paolo, Farina Claudio, Suter Fredi
U.O. di Cardiochirurgia, Azienda Ospedaliera Ospedali Riuniti Largo Barozzi, 24100 Bergamo.
Ital Heart J Suppl. 2002 Jul;3(7):728-37.
Aortic valve surgery for infective endocarditis is still a high-risk procedure and the optimal valve substitute remains controversial. The aim of this study was to evaluate the results of our experience using homografts in the treatment of native (NVE) or prosthetic valve endocarditis (PVE).
Between May 1992 and December 2000, 37 patients with NVE and 16 patients with PVE underwent aortic valve replacement with homografts for infective endocarditis. In the two groups of patients the mean age was 57 and 61 years and 38% and 50% were in NYHA functional class IV or V. At the time of surgery, 28 patients had gross vegetations, 23 single or multiple abscess cavities, 3 ventricular septal perforations, and 9 mitral valve endocarditis. Homograft insertion was performed in a subcoronary position in 47 cases and as a root replacement in 6 cases. In 21 cases associated surgical procedures were also performed.
Follow-up was 94% complete at a mean of 56 months after valve replacement. There were 1 hospital and 7 delayed deaths; the actuarial survival at 5 years was 85.5 +/- 6% for NVE and 80.8 +/- 10% for PVE. Endocarditis recurred early in 2 cases (both with fungal infection) and late in 3 cases with an endocarditis-free 5-year period of 87.1 +/- 5%. Delayed echocardiography demonstrated aortic incompetence classified as grade II in 40 cases and as grade III and IV in 2 cases. Thirty-nine patients are in NYHA class I and 3 in class II or III.
On the basis of our experience we can conclude that in case of acute endocarditis, if the results of surgery are to be optimized, an early diagnosis and aggressive medical therapy need to be combined with earlier surgical referral. In the presence of NVE without annular abscesses the likelihood of recurrent endocarditis is probably more likely to depend on the infective organism than on the type of valve implanted. Our results support the suggestion that in the presence of NVE with extensive annular abscesses or in case of PVE the homograft valve is the replacement device of choice.
感染性心内膜炎的主动脉瓣手术仍是一项高风险手术，最佳的瓣膜替代物仍存在争议。本研究的目的是评估我们使用同种异体移植物治疗原发性（NVE）或人工瓣膜心内膜炎（PVE）的经验结果。
1992年5月至2000年12月期间，37例NVE患者和16例PVE患者因感染性心内膜炎接受了同种异体移植物主动脉瓣置换术。两组患者的平均年龄分别为57岁和61岁，38%和50%的患者纽约心脏协会（NYHA）心功能分级为IV级或V级。手术时，28例患者有肉眼可见的赘生物，23例有单个或多个脓肿腔，3例有室间隔穿孔，9例有二尖瓣心内膜炎。47例患者在冠状动脉下位置植入同种异体移植物，6例患者进行根部置换。21例患者还进行了相关的外科手术。
瓣膜置换术后平均56个月时，随访完成率为94%。有1例住院死亡和7例延迟死亡；NVE患者5年的精算生存率为85.5±6%，PVE患者为80.8±10%。2例患者早期发生心内膜炎复发（均为真菌感染），3例患者晚期复发，无心内膜炎的5年发生率为87.1±5%。延迟超声心动图显示40例患者存在II级主动脉瓣关闭不全，2例患者为III级和IV级。39例患者纽约心脏协会心功能分级为I级，3例为II级或III级。
根据我们的经验可以得出结论，在急性心内膜炎的情况下，若要优化手术结果，早期诊断和积极的药物治疗需要与更早的手术转诊相结合。在无瓣环脓肿的NVE患者中，心内膜炎复发的可能性可能更多地取决于感染病原体而非植入瓣膜的类型。我们的结果支持以下建议，即在存在广泛瓣环脓肿的NVE患者或PVE患者中，同种异体移植物瓣膜是首选的置换装置。
