Gabbieri Davide, Dohmen Pascal M, Linneweber Jörg, Grubitzsch Herko, von Heymann Christian, Neumann Konrad, Halle Elke, Konertz Wolfgang F
Department of Cardiovascular Surgery, Charité Hospital, Medical University Berlin, Germany.
J Heart Valve Dis. 2008 Sep;17(5):508-24; discussion 525.
Today, the in-hospital mortality of patients treated surgically for active aortic native and prosthetic valve endocarditis remains high. The study aim was to identify the preoperative and intraoperative predictors of early outcome.
Between January 2004 and December 2006, 75 patients (57 males, 18 females; mean age 61.6 +/- 14.1 years) underwent surgery for active native valve (NVE) or prosthetic aortic valve endocarditis (PVE).
Active aortic NVE was present in 49 patients (65.3%), and PVE in 26 (34.7%). Staphylococcus species were the most common infecting microorganisms in both groups, while 20 cases (26.7%) were culture-negative. Except for significantly higher preoperative renal failure (RF) in patients with PVE (p = 0.01), the clinical characteristics were equally distributed. Four patient subsets were identified based on the extent of the infectious process: (i) locally controlled NVE (38.7%); (ii) locally uncontrolled NVE (26.7%); (iii) locally controlled PVE (14.6%); and (iv) locally uncontrolled PVE (20%). Aortic valve replacement (AVR) was performed with a stentless bioprosthesis in 53 cases (70.7%), a mechanical prosthesis in eight (10.6%), and a Ross procedure in 14 (18.7%). Concomitant active mitral valve endocarditis was treated in 17 patients (22.7%). Associated procedures were performed in 14 cases (18.7%). The in-hospital mortality was 24% (n = 18). Female gender (p = 0.0147), preoperative septic or cardiogenic shock (p = 0.0275) and previous embolic events (p = 0.0129) were identified as independent predictors for in-hospital mortality. Eight late deaths occurred; the estimated overall actuarial survival was 66.6 +/- 5.6% at 12 months and 60.7 +/- 6.5% at 24 months. On Cox multiple regression, age > 70 years (p = 0.0113), preoperative RF (p = 0.0015) and mitral valve surgery due to concomitant infective endocarditis (p = 0.0363) were significant adverse predictors of late death.
Surgery for active aortic valve infective endocarditis is associated with high operative mortality and morbidity. Failure of antibiotic therapy causing septic or cardiogenic shock and delayed referral to surgery may have a detrimental effect on early outcome. Surgical eradication of cardiac infections should always be associated with the treatment of extracardiac septic foci, which could maintain a septic state and adversely influence early outcome. Adhesion to surgical guidelines, together with a multidisciplinary approach, may have a major impact on the early prognosis of these high-risk patients.
如今，因主动脉原发性和人工瓣膜心内膜炎接受手术治疗的患者院内死亡率依然很高。本研究的目的是确定早期预后的术前和术中预测因素。
在2004年1月至2006年12月期间，75例患者（57例男性，18例女性；平均年龄61.6±14.1岁）因活动性原发性瓣膜（NVE）或人工主动脉瓣膜心内膜炎（PVE）接受了手术。
49例患者（65.3%）存在活动性主动脉NVE，26例（34.7%）存在PVE。葡萄球菌属是两组中最常见的感染微生物，而20例（26.7%）血培养阴性。除PVE患者术前肾衰竭（RF）显著更高（p = 0.01）外，临床特征分布均衡。根据感染过程的范围确定了四个患者亚组：（i）局部控制的NVE（38.7%）；（ii）局部未控制的NVE（26.7%）；（iii）局部控制的PVE（14.6%）；以及（iv）局部未控制的PVE（20%）。53例（70.7%）患者采用无支架生物瓣膜进行主动脉瓣置换（AVR），8例（10.6%）采用机械瓣膜，14例（18.7%）采用罗斯手术。17例患者（22.7%）同时治疗了活动性二尖瓣心内膜炎。14例患者（18.7%）进行了相关手术。院内死亡率为24%（n = 18）。女性（p = 0.0147）、术前感染性或心源性休克（p = 0.0275）以及既往栓塞事件（p = 0.0129）被确定为院内死亡的独立预测因素。发生了8例晚期死亡；估计12个月时的总体精算生存率为66.6±5.6%，24个月时为60.7±6.5%。在Cox多元回归分析中，年龄>70岁（p = 0.0113）、术前RF（p = 0.0015）以及因合并感染性心内膜炎进行二尖瓣手术（p = 0.0363）是晚期死亡的显著不良预测因素。
活动性主动脉瓣感染性心内膜炎手术的手术死亡率和发病率较高。抗生素治疗失败导致感染性或心源性休克以及延迟转诊进行手术可能对早期预后产生不利影响。心脏感染的手术根除应始终与心外感染灶的治疗相结合，因为心外感染灶可能维持感染状态并对早期预后产生不利影响。遵守手术指南并采用多学科方法可能对这些高危患者的早期预后产生重大影响。
