Denk Katja, Vahl Christian-Friedrich
Klinik für Herz-, Thorax-undGefässchirurgie, Universitätsmedizin, Mainz.
Herz. 2009 May;34(3):198-205. doi: 10.1007/s00059-009-3232-7.
Treatment of infective endocarditis is primarily conservative. Persistent infection, tissue destruction und hemodynamic instabilities argue - in dependence on the microorganisms involved - for an urgent surgical treatment, even when there is still no control of the local and systemic infection. For timing of the surgical intervention, the following suggestions seem to be valid: TIMING OF THE SURGICAL INTERVENTION: Delayed surgical indication is considered a prognostic factor of extraordinary relevance for surgical treatment of infective endocarditis. Presence of intramyocardial, paravalvular and root abscess or development of a septic cardiomyopathy (in addition to the valve-related disturbed pump and muscular function), systemic sepsis and irreversible extracardiac organ destruction (liver, spleen, kidney, brain, lung, bone, etc.) reduce the surgical prognosis even after successful and complete surgical treatment. Extracardiac foci may determine the postoperative course. After cerebral embolization the cardiac operation should be performed as early as possible (within 24-48 h after embolization). Extreme extent of cardiac and extracardiac tissue destruction due to delayed surgical indication can result in a situation, where adequate surgical treatment of the local focus is not likely to be successful anymore and prognosis becomes infaust. In their own patients, the authors observed: NYHA (New York Heart Association) III-IV > 50%; renal failure (dialysis) > 15%, systemic embolization > 30%, cerebral embolization > 8%, cardiogenic shock > 10%.
The most important aspect is complete debridement of all infected tissue with a safety margin of about 3 mm. This holds true, even if it results in resection of the entire aortic root, mitral ring, aortic wall, and atrial tissue. There is no contraindication to the implantation of prosthetic materials (valves, bovine pericardium, mitral rings) as long as surgical debridement has been prompt and aggressive. Not the type of prosthesis, but the quality of surgical debridement is of prognostic relevance. Reconstructive techniques are suggested whenever possible and are primarily effective for the treatment of mitral and tricuspid valves. Prompt and aggressive eradication of extracardiac foci is important to the patient's postoperative course.
After successful surgical treatment of the intracardiac focus, the postoperative course is mainly determined by extracardiac foci, systemic sepsis, and persistent secondary organ destruction.
As the results of conservative treatment of infective endocarditis are still not satisfactory, in some subgroups improved surgical results due to aggressive and radical debridement of infective tissue (with a safety margin of at least 3 mm) will suggest the surgical treatment option even in those patients, that have primarily been considered for conservative treatment.
感染性心内膜炎的治疗主要是保守治疗。持续感染、组织破坏和血流动力学不稳定表明，根据所涉及的微生物不同，即使局部和全身感染仍未得到控制，也需要紧急进行手术治疗。对于手术干预的时机，以下建议似乎是有效的：
延迟手术指征被认为是感染性心内膜炎手术治疗的一个极其重要的预后因素。存在心肌内、瓣周和根部脓肿或发生感染性心肌病（除了与瓣膜相关的泵功能和肌肉功能障碍外）、全身性败血症和不可逆的心外器官破坏（肝脏、脾脏、肾脏、大脑、肺、骨骼等）即使在成功完成手术治疗后也会降低手术预后。心外病灶可能决定术后病程。脑栓塞后应尽早进行心脏手术（栓塞后24 - 48小时内）。由于延迟手术指征导致心脏和心外组织破坏的程度极为严重，可能会导致一种情况，即对局部病灶进行充分的手术治疗不太可能再成功，预后变得不佳。作者在自己的患者中观察到：纽约心脏协会（NYHA）III - IV级＞50%；肾衰竭（透析）＞15%，全身性栓塞＞30%，脑栓塞＞8%，心源性休克＞10%。
最重要的方面是彻底清除所有感染组织，安全 margins 约为3毫米。即使这导致切除整个主动脉根部、二尖瓣环、主动脉壁和心房组织，也是如此。只要手术清创及时且积极，植入人工材料（瓣膜、牛心包、二尖瓣环）就没有禁忌证。与预后相关的不是假体的类型，而是手术清创的质量。只要有可能，建议采用重建技术，主要用于治疗二尖瓣和三尖瓣。及时、积极地根除心外病灶对患者的术后病程很重要。
心内病灶成功手术治疗后，术后病程主要由心外病灶、全身性败血症和持续性继发性器官破坏决定。
由于感染性心内膜炎的保守治疗结果仍不令人满意，在一些亚组中，由于对感染组织进行积极、彻底的清创（安全 margins至少为3毫米），即使在那些最初被认为适合保守治疗的患者中，手术治疗方案也可能更合适。
