感染性心内膜炎合并心力衰竭患者行瓣膜手术后的死亡率。
Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure.
机构信息
Duke University Medical Center, Durham, NC 27710, USA.
出版信息
JAMA. 2011 Nov 23;306(20):2239-47. doi: 10.1001/jama.2011.1701.
CONTEXT
Heart failure (HF) is the most common complication of infective endocarditis. However, clinical characteristics of HF in patients with infective endocarditis, use of surgical therapy, and their associations with patient outcome are not well described.
OBJECTIVES
To determine the clinical, echocardiographic, and microbiological variables associated with HF in patients with definite infective endocarditis and to examine variables independently associated with in-hospital and 1-year mortality for patients with infective endocarditis and HF, including the use and association of surgery with outcome.
DESIGN, SETTING, AND PATIENTS: The International Collaboration on Endocarditis-Prospective Cohort Study, a prospective, multicenter study enrolling 4166 patients with definite native- or prosthetic-valve infective endocarditis from 61 centers in 28 countries between June 2000 and December 2006.
MAIN OUTCOME MEASURES
In-hospital and 1-year mortality.
RESULTS
Of 4075 patients with infective endocarditis and known HF status enrolled, 1359 (33.4% [95% CI, 31.9%-34.8%]) had HF, and 906 (66.7% [95% CI, 64.2%-69.2%]) were classified as having New York Heart Association class III or IV symptom status. Within the subset with HF, 839 (61.7% [95% CI, 59.2%-64.3%]) underwent valvular surgery during the index hospitalization. In-hospital mortality was 29.7% (95% CI, 27.2%-32.1%) for the entire HF cohort, with lower mortality observed in patients undergoing valvular surgery compared with medical therapy alone (20.6% [95% CI, 17.9%-23.4%] vs 44.8% [95% CI, 40.4%-49.0%], respectively; P < .001). One-year mortality was 29.1% (95% CI, 26.0%-32.2%) in patients undergoing valvular surgery vs 58.4% (95% CI, 54.1%-62.6%) in those not undergoing surgery (P < .001). Cox proportional hazards modeling with propensity score adjustment for surgery showed that advanced age, diabetes mellitus, health care-associated infection, causative microorganism (Staphylococcus aureus or fungi), severe HF (New York Heart Association class III or IV), stroke, and paravalvular complications were independently associated with 1-year mortality, whereas valvular surgery during the initial hospitalization was associated with lower mortality.
CONCLUSION
In this cohort of patients with infective endocarditis complicated by HF, severity of HF was strongly associated with surgical therapy and subsequent mortality, whereas valvular surgery was associated with lower in-hospital and 1-year mortality.
背景
心力衰竭（HF）是感染性心内膜炎最常见的并发症。然而，患有感染性心内膜炎的患者中 HF 的临床特征、手术治疗的应用以及它们与患者预后的关系尚未得到很好的描述。
目的
确定明确感染性心内膜炎患者中与 HF 相关的临床、超声心动图和微生物学变量，并研究与感染性心内膜炎和 HF 患者住院和 1 年死亡率相关的变量，包括手术的应用及其与结局的关系。
设计、地点和患者：国际心内膜炎协作前瞻性队列研究，这是一项前瞻性、多中心研究，纳入了 2000 年 6 月至 2006 年 12 月期间来自 28 个国家 61 个中心的 4166 例明确的原发性或人工瓣膜感染性心内膜炎患者。
主要观察指标
住院期间和 1 年死亡率。
结果
在已知 HF 状态的 4075 例感染性心内膜炎患者中，1359 例（33.4%[95%CI，31.9%-34.8%]）患有 HF，906 例（66.7%[95%CI，64.2%-69.2%]）被归类为纽约心脏协会（NYHA）III 或 IV 级症状状态。在 HF 亚组中，839 例（61.7%[95%CI，59.2%-64.3%]）在住院期间接受了瓣膜手术。HF 整个队列的住院死亡率为 29.7%（95%CI，27.2%-32.1%），与单独接受药物治疗相比，接受瓣膜手术的患者死亡率较低（20.6%[95%CI，17.9%-23.4%]与 44.8%[95%CI，40.4%-49.0%]；P<.001）。接受瓣膜手术的患者 1 年死亡率为 29.1%（95%CI，26.0%-32.2%），未接受手术的患者为 58.4%（95%CI，54.1%-62.6%）（P<.001）。经手术倾向性评分调整的 Cox 比例风险模型显示，年龄较大、糖尿病、与医疗保健相关的感染、病原体（金黄色葡萄球菌或真菌）、严重 HF（NYHA 分级 III 或 IV）、中风和瓣周并发症与 1 年死亡率独立相关，而住院期间的瓣膜手术与较低的死亡率相关。
结论
在患有 HF 合并感染性心内膜炎的患者队列中，HF 的严重程度与手术治疗和随后的死亡率密切相关，而瓣膜手术与住院和 1 年死亡率降低相关。
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