Wang Zhi-Nong, Zhang Bao-Ren, Xu Zhi-Yun, Hao Jia-Hua, Zou Liang-Jian, Mei Ju, Xu Ji-Bin
Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China.
Zhonghua Wai Ke Za Zhi. 2004 Jun 7;42(11):657-60.
To elucidate the early and long-term results of surgical treatment for complex infective endocarditis with prosthetic valve replacement.
Fifty-seven patients of complex native valve endocarditis, including 25 cases of aortic valve, 16 of mitral valve and 16 of double valves, who underwent operative interventions with prosthetic valve replacement between December 1988 and June 2002, were analyzed retrospectively. Intraoperative findings demonstrated aortic annular abscesses (n = 19), root abscesses (n = 4), mitral posterior annular abscesses (n = 11), myocardial abscesses (n = 6), massive leaflet destruction (n = 32) and valvular vegetations (n = 55). Complex reconstruction of the aortic and mitral annulus was required in 35 patients. Associated procedures included Bentall's procedure (n = 4), aortic valve replacement (n = 21), mitral valve replacement (n = 16) and double valve replacements (n = 16).
The operative mortality was 11%. Complications included low cardiac output syndrome, recurrence of endocarditis, multiple organ failure, ventricular arrhythmia, bleeding, mediastinal infection, respiratory insufficiency and heart block. Follow-up was 100% complete at a mean of 5.93 years. There were five late deaths (3 prosthetic valve endocarditis, 2 valve-related). The NYHA functional status recovered to Class I in 17 patients, Class II in 27 and Class III in 2 at 1 year follow-up. Kaplan-Meier analysis showed the 5-year actuarial freedom from reoperation was (84 +/- 3)%, and actuarial survivorship at 5 years was (61 +/- 9)%.
Urgent or even emergency operation is advocated for complex infective endocarditis. Proper intraoperative reconstruction of the aortic and mitral annulus and optimized perioperative management, especially the strategy for prevention of recurrent endocarditis, are of great importance in achieving satisfied early and long-term clinical outcomes.
阐明人工瓣膜置换术治疗复杂感染性心内膜炎的早期和长期结果。
回顾性分析1988年12月至2002年6月期间接受人工瓣膜置换术的57例复杂性天然瓣膜心内膜炎患者，其中主动脉瓣25例，二尖瓣16例，双瓣膜16例。术中发现主动脉瓣环脓肿（n = 19）、根部脓肿（n = 4）、二尖瓣后瓣环脓肿（n = 11）、心肌脓肿（n = 6）、瓣叶大量破坏（n = 32）和瓣膜赘生物（n = 55）。35例患者需要对主动脉瓣环和二尖瓣环进行复杂重建。相关手术包括Bentall手术（n = 4）、主动脉瓣置换术（n = 21）、二尖瓣置换术（n = 16）和双瓣膜置换术（n = 16）。
手术死亡率为11%。并发症包括低心排血量综合征、心内膜炎复发、多器官功能衰竭、室性心律失常、出血、纵隔感染、呼吸功能不全和心脏传导阻滞。随访率为100%，平均随访时间为5.93年。有5例晚期死亡（3例人工瓣膜心内膜炎，2例与瓣膜相关）。在1年随访时，纽约心脏协会（NYHA）心功能分级恢复到I级的有17例，II级的有27例，III级的有2例。Kaplan-Meier分析显示，5年再次手术的精算自由度为（84±3）%，5年精算生存率为（61±9）%。
对于复杂感染性心内膜炎，提倡进行紧急甚至急诊手术。术中对主动脉瓣环和二尖瓣环进行适当重建以及优化围手术期管理，尤其是预防心内膜炎复发的策略，对于获得满意的早期和长期临床结果至关重要。
