Anguera Ignasi, Miro Jose M, Vilacosta Isidre, Almirante Benito, Anguita Manuel, Muñoz Patricia, San Roman Jose Alberto, de Alarcon Aristides, Ripoll Tomas, Navas Enrique, Gonzalez-Juanatey Carlos, Cabell Christopher H, Sarria Cristina, Garcia-Bolao Ignacio, Fariñas M Carmen, Leta Ruben, Rufi Gabriel, Miralles Francisco, Pare Carles, Evangelista Artur, Fowler Vance G, Mestres Carlos A, de Lazzari Elisa, Guma Joan R
Corporacio Sanitaria Parc Tauli-Hospital de Sabadell, Sabadell, Spain.
Eur Heart J. 2005 Feb;26(3):288-97. doi: 10.1093/eurheartj/ehi034. Epub 2004 Nov 30.
To investigate the clinical features, echocardiographic characteristics, management, and prognostic factors of mortality of aorto-cavitary fistulization (ACF) in infective endocarditis (IE). Extension of infection in aortic valve IE beyond valvular structures may result in peri-annular complications with resulting necrosis and rupture, and subsequent development of ACF. Aorto-cavitary communications create intra-cardiac shunts, which may result in further clinical deterioration and haemodynamic instability.
In a retrospective multi-centre study over 4681 episodes of IE, a total of 76 patients with ACF [1.6%, confidence interval (CI) 95%: 1.2-2.0%] diagnosed by echocardiography or during surgery were identified. Fistulae were found in 1.8% of cases of native valve IE and in 3.5% of cases of prosthetic valve IE from the general population and in 0.4% of drug abusers. PVE was present in 31 (41%) cases of ACF. Transthoracic and transoesophageal echocardiography detected the fistulous tracts in 53 and 97% of cases, respectively. Peri-annular abscesses were detected in 78% of cases, fistulae originated in similar rates from the three sinuses of Valsalva, and the four cardiac chambers were equally involved in the fistulous tracts. Heart failure (HF) developed in 62% of cases and surgery was performed in 66 (87% CI 95% 77-93%) patients with a mortality of 41% (95% CI 30-53%) in the overall population. Multivariate analysis identified HF (OR 3.4, CI 95% 1.0-11.5), prosthetic IE (OR 4.6, CI 95% 1.4-15.4) and urgent or emergency surgical treatment (OR 4.3, CI 95% 1.3-16.6) as variables significantly associated with an increased risk of death. Major complications during follow-up (death, re-operation, or re-admission for HF) among the five operative survivors with residual fistulae occurred in 20 and 100% of patients at 1 and 2 years, respectively.
Aorto-cavitary fistulous tract formation is an uncommon but extremely serious complication of IE. In-hospital mortality was exceptionally high despite aggressive management with surgical intervention in the majority of patients. Prosthetic IE, urgent surgery, and the development of HF identify the subgroup of patients with IE and ACF that have significantly increased risk of in-hospital death.
研究感染性心内膜炎（IE）中主动脉-心腔瘘（ACF）的临床特征、超声心动图特点、治疗及死亡预后因素。主动脉瓣IE的感染超出瓣膜结构可导致瓣周并发症，进而引起坏死和破裂，随后发展为ACF。主动脉-心腔交通形成心内分流，可导致临床进一步恶化和血流动力学不稳定。
在一项对4681例IE病例的回顾性多中心研究中，通过超声心动图或手术共确诊76例ACF患者[1.6%，95%置信区间（CI）：1.2 - 2.0%]。在普通人群中，天然瓣膜IE病例的瘘管发生率为1.8%，人工瓣膜IE病例为3.5%，药物滥用者为0.4%。31例（41%）ACF患者存在人工瓣膜心内膜炎（PVE）。经胸和经食管超声心动图分别在53%和97%的病例中检测到瘘管。78%的病例检测到瓣周脓肿，瘘管起源于三个主动脉窦的比例相似，四个心腔均同等程度地累及瘘管。62%的病例发生心力衰竭（HF），66例（95%CI 87% 77 - 93%）患者接受了手术，总体人群死亡率为41%（95%CI 30 - 53%）。多因素分析确定HF（比值比3.4，95%CI 1.0 - 11.5）、人工瓣膜IE（比值比4.6，95%CI 1.4 - 15.4）以及紧急或急诊手术治疗（比值比4.3，95%CI 1.3 - 16.6）为与死亡风险增加显著相关的变量。在5例有残余瘘管的手术幸存者中，随访期间的主要并发症（死亡、再次手术或因HF再次入院）在1年和2年时分别发生在20%和100%的患者中。
主动脉-心腔瘘管形成是IE一种罕见但极其严重的并发症。尽管大多数患者积极接受手术干预治疗，但住院死亡率极高。人工瓣膜IE、紧急手术以及HF的发生确定了IE合并ACF且住院死亡风险显著增加的患者亚组。
