Hagl Christian, Galla Jan D, Lansman Steven L, Fink Daniel, Bodian Carol A, Spielvogel David, Griepp Randall B
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York, USA.
Ann Thorac Surg. 2002 Nov;74(5):S1781-5; discussion S1792-9. doi: 10.1016/s0003-4975(02)04142-5.
The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval.
Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1).
Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months.
These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.
在急性人工瓣膜心内膜炎病例中，使用人工材料（而非同种异体移植物）进行升主动脉/主动脉瓣置换术（Bentall手术）存在争议。我们报告了在12年期间几乎完全使用该技术（仅3例血液系统问题患者使用了同种异体移植物）所取得的良好结果。
1988年至2000年间，28例患者（年龄55±14岁；男性22例）因急性人工瓣膜心内膜炎接受了Bentall手术。25例患者曾接受过主动脉瓣置换术（1例同时进行二尖瓣置换术，4例进行冠状动脉搭桥术），3例曾接受过Bentall手术。初次手术与再次手术之间的中位间隔时间为13个月（范围1至106个月）。68%的手术为急诊或紧急手术。93%的患者有严重主动脉瓣反流；71%发生了完全性主动脉瓣环-主动脉瓣分离，57%发现有脓肿。28例患者中有25例确定了致病微生物：表皮葡萄球菌（9例）、金黄色葡萄球菌（7例）、草绿色链球菌（6例）、铜绿假单胞菌（2例）和军团菌（1例）。
23例患者在Bentall手术期间植入了机械瓣膜，5例植入了生物瓣膜。64%的患者使用了低温循环停搏。医院死亡率为11%：1例术中死亡，2例出院前死亡（1例死于心脏原因，1例死于败血症）。89%的患者存活且无卒中。在随访期间（中位时间44.5个月；92%完成随访），1例患者在4个月时死于复发性心内膜炎。
这些结果表明，对于急性主动脉人工瓣膜心内膜炎，人工瓣膜根部置换术可能优于使用同种异体移植物，复发性心内膜炎和再次手术的发生率仅为4%。
