Hickey Edward J, Jung Gordon, Manlhiot Cedric, Sakopoulos Andreas G, Caldarone Christopher A, Coles John G, Van Arsdell Glen S, McCrindle Brian W
Department of Surgery, Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Canada.
Eur J Cardiothorac Surg. 2009 Jan;35(1):130-5. doi: 10.1016/j.ejcts.2008.08.020. Epub 2008 Sep 30.
Recent reports describing surgical experiences with childhood IE are sparse. We sought to determine patient-specific characteristics and their impact on outcome for children with infective endocarditis (IE) undergoing surgical intervention. We therefore reviewed all cases of culture-proven IE referred for surgical intervention at our institution over the last three decades.
Of 15,124 cardiovascular surgical procedures performed between 1978 and 2007 at our institution on children under the age of 18, only 30 (0.2%) were undertaken for a primary diagnosis of IE. All 30 children underwent chart review and retrospective risk-hazard analysis.
Median patient age was 9.8 years (range 10 weeks to 17.5 years). Underlying congenital cardiac lesions were present in 22 (77%) and previous intra-cardiac repair in 9 (30%). Septic emboli occurred in 13 (46%), causing permanent strokes in 4 (14%). Streptococcus viridans and Staphylococcus aureus were the predominant organisms. S. viridans was associated with underlying congenital lesions (p<0.01). S. aureus was associated with abscess formation (p<0.03), clinical sepsis (p<0.04), acute deterioration (p<0.01), prolonged hospitalization (p<0.01) and death (p<0.01). Aortic, mitral and tricuspid valves were involved with equal frequency, more than the right ventricular outflow tract. Two valves were involved in 30%. The native valve was preserved at operation in 22 (73% cases). Univariate predictors for valve replacement included increased leaflet thickening (p<0.01) and occurrence of septic embolization (p=0.02), whereas moderate/severe valvular regurgitation was not significant. Five-year freedom from IE-related death and re-intervention was 84% and 80%, respectively. At latest follow-up 96% of patients are NHYA I.
Children undergoing surgery for infective endocarditis frequently have advanced disease with embolic complications and double valve involvement. However, preservation of the native valve is frequently possible. Need for valve replacement is suggested by leaflet thickening and embolization. Despite the advanced pathology, survival and functional outcomes are favorable.
近期关于儿童感染性心内膜炎手术经验的报道较少。我们试图确定接受手术干预的感染性心内膜炎（IE）患儿的个体特征及其对预后的影响。因此，我们回顾了过去三十年在我院接受手术干预的所有经培养证实的IE病例。
1978年至2007年间，我院对18岁以下儿童进行了15124例心血管外科手术，其中仅30例（0.2%）的初步诊断为IE。对所有30例患儿进行了病历审查和回顾性风险-危害分析。
患者中位年龄为9.8岁（范围10周龄至17.5岁）。22例（77%）存在潜在先天性心脏病变，9例（30%）曾接受过心脏内修复术。13例（46%）发生感染性栓子，4例（14%）导致永久性中风。草绿色链球菌和金黄色葡萄球菌是主要病原体。草绿色链球菌与潜在先天性病变相关（p<0.01）。金黄色葡萄球菌与脓肿形成（p<0.03）、临床败血症（p<0.04）、急性病情恶化（p<0.01）、住院时间延长（p<0.01）和死亡（p<0.01）相关。主动脉瓣、二尖瓣和三尖瓣受累频率相同，高于右心室流出道。30%的患儿累及两个瓣膜。22例（73%）在手术中保留了自身瓣膜。瓣膜置换的单因素预测因素包括瓣叶增厚增加（p<0.01）和感染性栓子形成（p=0.02），而中度/重度瓣膜反流不显著。IE相关死亡和再次干预的5年无事件生存率分别为84%和80%。在最近一次随访时，96%的患者为纽约心脏协会（NHYA）I级。
接受感染性心内膜炎手术的儿童常患有晚期疾病，伴有栓塞并发症和双瓣膜受累。然而，通常可以保留自身瓣膜。瓣叶增厚和栓塞提示需要进行瓣膜置换。尽管病理情况严重，但生存和功能预后良好。
