Wang Andrew, Pappas Paul, Anstrom Kevin J, Abrutyn Elias, Fowler Vance G, Hoen Bruno, Miro Jose M, Corey G Ralph, Olaison Lars, Stafford Judith A, Mestres Carlos A, Cabell Christopher H
Department of Medicine, Duke University Medical Center, Durham, NC, USA.
Am Heart J. 2005 Nov;150(5):1086-91. doi: 10.1016/j.ahj.2005.01.023.
Although surgical intervention is often used in the treatment of prosthetic valve infective endocarditis (PVIE), an understanding of its effect on survival has been limited by the biases of observational studies and lack of controlled trials.
The International Collaboration on Endocarditis Merged Database is a large, multicenter, international registry of patients with definite endocarditis by Duke criteria, including 367 patients with PVIE. Clinical, microbiologic, and echocardiographic variables were analyzed to determine those factors associated with the use of surgery for PVIE. Logistic regression analysis was performed to create a propensity model of predictors of surgery use. Patients who underwent surgery during initial hospitalization were matched by propensity score with patients treated with medical therapy alone. Logistic regression analysis was performed to determine variables independently associated with inhospital mortality in this matched subset.
Surgical therapy for PVIE was performed in 148 (42%) of 367 patients. Inhospital mortality was similar for patients treated with surgery compared with those treated with medical therapy alone (25.0% vs 23.4%, P = .729). Surgical therapy was independently associated with patient age, microorganism, intracardiac abscess, and congestive heart failure. After adjustment for these determinants, inhospital mortality was predicted by brain embolization (OR 11.12, 95% CI 4.16-29.73) and Staphylococcus aureus infection (OR 3.67, 95% CI 1.29-9.74), with a trend toward benefit for surgery (OR 0.56, 95% CI 0.23-1.36).
Despite the frequent use of surgery for the treatment of PVIE, this condition continues to be associated with a high inhospital mortality rate in the contemporary era. After adjustment for factors related to surgical intervention, brain embolism and S aureus infection were independently associated with inhospital mortality and a trend toward a survival benefit of surgery was evident.
尽管手术干预常用于人工瓣膜感染性心内膜炎（PVIE）的治疗，但观察性研究的偏倚和缺乏对照试验限制了对其生存影响的理解。
国际心内膜炎协作合并数据库是一个大型、多中心、国际登记处，纳入符合杜克标准的明确心内膜炎患者，其中包括367例PVIE患者。分析临床、微生物学和超声心动图变量，以确定与PVIE手术治疗相关的因素。进行逻辑回归分析以建立手术使用预测因子的倾向模型。在初次住院期间接受手术的患者按倾向评分与仅接受药物治疗的患者进行匹配。进行逻辑回归分析以确定该匹配亚组中与住院死亡率独立相关的变量。
367例患者中有148例（42%）接受了PVIE手术治疗。与仅接受药物治疗的患者相比，接受手术治疗的患者住院死亡率相似（25.0%对23.4%，P = 0.729）。手术治疗与患者年龄、微生物、心内脓肿和充血性心力衰竭独立相关。在对这些决定因素进行调整后，脑栓塞（OR 11.12，95% CI 4.16 - 29.73）和金黄色葡萄球菌感染（OR 3.67，95% CI 1.29 - 9.74）可预测住院死亡率，手术有获益趋势（OR 0.56，95% CI 0.23 - 1.36）。
尽管手术常用于PVIE的治疗，但在当代，这种疾病的住院死亡率仍然很高。在对与手术干预相关的因素进行调整后，脑栓塞和金黄色葡萄球菌感染与住院死亡率独立相关，手术有生存获益趋势明显。
