Anguera Ignasi, Miro Jose M, Evangelista Artur, Cabell Christopher H, San Roman Jose Alberto, Vilacosta Isidre, Almirante Benito, Ripoll Tomas, Fariñas M Carmen, Anguita Manuel, Navas Enrique, Gonzalez-Juanatey Carlos, Garcia-Bolao Ignacio, Muñoz Patricia, de Alarcon Aristides, Sarria Cristina, Rufi Gabriel, Miralles Francisco, Pare Carles, Fowler Vance G, Mestres Carlos A, de Lazzari Elisa, Guma Joan R, Moreno Asunción, Corey G Ralph
Corporacio Sanitaria Parc Tauli-Hospital de Sabadell, Sabadell, Spain.
Am J Cardiol. 2006 Nov 1;98(9):1254-60. doi: 10.1016/j.amjcard.2006.06.016. Epub 2006 Sep 14.
The extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.
自体瓣膜感染性心内膜炎（IE）中感染从瓣膜结构扩展至瓣周组织的情况尚未完全明确。例如，主动脉腔瘘患者的预后是否比未破裂脓肿患者更差尚不清楚。本研究的目的是确定自体瓣膜IE中主动脉腔瘘和未破裂脓肿患者的不同临床特征，并评估瘘管形成对并发瓣周病变的自体主动脉瓣IE患者预后的影响。在一项对2055例自体瓣膜IE发作的回顾性多中心研究中，确定了201例（9.8%）主动脉瓣IE并发瓣周并发症的患者（46例有主动脉腔瘘形成，155例有未破裂脓肿）。瘘管形成患者的心力衰竭（p = 0.07）、室间隔缺损（p <0.001）和三度房室传导阻滞（p = 0.07）发生率更高。172例患者（86%）接受了手术治疗，总体人群的住院死亡率为29%。多变量分析确定年龄>60岁（比值比[OR] 2.6，95%置信区间[CI] 1.3至5.2）、肾衰竭（OR 3.0，95% CI 1.5至6.0）以及中度或重度心力衰竭（OR 2.5，95% CI 1.2至5.2）为死亡的独立危险因素。主动脉腔瘘患者的住院死亡率有增加趋势（OR 1.5，95% CI 0.7至3.0）。手术存活患者中，瘘管患者的5年精算生存率为80%，未破裂脓肿患者为92%（对数秩检验p = 0.6）。总之，自体瓣膜IE情况下主动脉腔瘘管形成与心力衰竭、室间隔缺损和房室传导阻滞的发生率高于未破裂脓肿有关。尽管并发症发生率较高，但在当前IE时代，瘘管形成并非死亡的独立危险因素。
