Siniawski Henryk, Grauhan Onnen, Hofmann Michael, Pasic Miralem, Weng Yuguo, Yankah Charles, Lehmkuhl Hans, Hetzer Roland
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
Eur J Cardiothorac Surg. 2005 Mar;27(3):434-40. doi: 10.1016/j.ejcts.2004.12.001. Epub 2005 Jan 13.
Mortality in active infective endocarditis (AIE) is substantial and reinfection can strongly influence outcome. Assessment of factors influencing mortality is important. We studied 108 (33%) patients suffering from root abscess out of a total of 327 AIE patients admitted to the Deutsches Herzzentrum Berlin for surgical treatment between 1996 and 2003. Among them were 53 (25.5% of all patients) who were diagnosed as having secondary infective mitral valve disease (SMVD). Mean age was 53+/-14.2 years; there were 37 men and 16 women.
Risk factors were assessed on the basis of clinical, hemodynamic, echocardiographic and surgical information. Mean follow-up was 325+/-251 days with complete echocardiographic examination performed in patients with double valve surgery. The differences between groups were analyzed using Student's t-test. Multivariate analysis for the whole group suffering from abscess was performed to identify independent factors influencing mortality.
In 19 (35.8%) patients suffering from SMVD mitral valve reconstruction was undertaken and mitral valve replacement was performed in 34 (64.2%) patients. There were 27 patients treated with a Shelhigh prosthesis: 18 with double valve replacement (both Shelhigh) and nine with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral reconstruction in 10 and a stented mitral prosthesis in seven. In nine cases two stented valve prostheses were used. The calculated mean Doppler gradient for homografts and Shelhigh in aortic position was 12 (+/-5.7) and 15 (+/-4.6), respectively (NS). The following predisposing factors for mortality were assessed: severe damage of aortic annulus (OR 4.65, CI 1.22-17.1, P=0.0159); septic shock (OR 3.44, CI 0.85-13.9, P=0.07) and poor ejection fraction (<40%), and dilated LV.
Excessive mortality reaching 29% was noted in patients suffering from AIE with aortic ring abscess and SMVD requiring double valve surgery. Double valve surgery with semi-stented Dacron-free valve prostheses is associated with a low rate of reinfection and good function of the implants. The most potent independent risk factors for death were septic shock and severe aortic root destruction.
活动性感染性心内膜炎（AIE）的死亡率很高，再感染会严重影响预后。评估影响死亡率的因素很重要。我们研究了1996年至2003年间在柏林德国心脏中心接受手术治疗的327例AIE患者中的108例（33%）患有根部脓肿的患者。其中53例（占所有患者的25.5%）被诊断为继发性感染性二尖瓣疾病（SMVD）。平均年龄为53±14.2岁；男性37例，女性16例。
根据临床、血流动力学、超声心动图和手术信息评估危险因素。平均随访时间为325±251天，对接受双瓣膜手术的患者进行了完整的超声心动图检查。采用Student's t检验分析组间差异。对整个脓肿患者组进行多变量分析，以确定影响死亡率的独立因素。
19例（35.8%）患有SMVD的患者进行了二尖瓣重建，34例（64.2%）患者进行了二尖瓣置换。27例患者使用了Shelhigh假体：18例进行了双瓣膜置换（均为Shelhigh），9例使用了主动脉Shelhigh假体并同时进行了二尖瓣重建。17例患者使用了同种异体移植物，10例进行了二尖瓣重建，7例使用了带支架的二尖瓣假体。9例患者使用了两个带支架的瓣膜假体。计算得出同种异体移植物和主动脉位置的Shelhigh的平均多普勒梯度分别为12（±5.7）和15（±4.6）（无显著性差异）。评估了以下死亡的易感因素：主动脉瓣环严重损伤（比值比4.65，可信区间1.22 - 17.1，P = 0.0159）；感染性休克（比值比3.44，可信区间0.85 - 13.9，P = 0.07）以及射血分数低（<40%）和左心室扩张。
患有AIE且伴有主动脉环脓肿和SMVD需要进行双瓣膜手术的患者死亡率高达29%。使用无涤纶半带支架瓣膜假体进行双瓣膜手术与再感染率低和植入物功能良好相关。死亡的最主要独立危险因素是感染性休克和严重的主动脉根部破坏。
