Service de Réanimation Médicale, Institut de Cardiologie, Université Paris VI-Pierre et Marie Curie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
Eur Heart J. 2014 May;35(18):1195-204. doi: 10.1093/eurheartj/eht303. Epub 2013 Aug 20.
To assess long-term outcomes and the management of critical left-sided infective endocarditis (IE) and evaluate the impact of surgery.
Among the 198 patients included prospectively for IE across 33 adult intensive care units (ICU) in France from 1 April 2007 to 1 October 2008, 137 (69%) were dead at a median follow-up time of 59.5 months. Characteristics significantly associated with mortality were: Sepsis-related Organ-Failure Assessment (SOFA) score at ICU admission [Hazard ratio (HR), 95% Confidence Interval (CI) of 1.43 (0.79-2.59) for SOFA 5-9; 2.01 (1.05-3.85) for SOFA 10-14; 3.53 (1.75-7.11) for SOFA 15-20; reference category SOFA 0-4; P = 0.003]; prosthetic mechanical valve IE [HR 2.01; 95% CI 1.09-3.69, P = 0.025]; vegetation size ≥15 mm [HR 1.64; 95% CI 1.03-2.63, P = 0.038]; and cardiac surgery [HR (95%CI), 0.33 (0.16-0.67) for surgery ≤1 day after IE diagnosis; 0.61 (0.29-1.26) for surgery 2-7 days after IE diagnosis; 0.42 (0.21-0.83) for surgery >7 days after IE diagnosis; reference category no surgery; P = 0.005]. One hundred and three (52%) patients underwent cardiac surgery after a median time of 6 (16) days. Independent predictors of surgical intervention on multivariate analysis were: age ≤60 years [Odds ratio (OR) 5.30; 95% CI (2.46-11.41), P < 0.01], heart failure [OR 3.27; 95% CI (1.03-10.35), P = 0.04], cardiogenic shock [OR 3.31; 95% CI (1.47-7.46), P = 0.004], septic shock [OR 0.25; 95% CI (0.11-0.59), P = 0.002], immunosuppression [OR 0.15; 95% CI (0.04-0.55), P = 0.004], and diagnosis before or within 24 h of ICU admission [OR 2.81; 95% CI (1.14-6.95), P = 0.025]. SOFA score calculated the day of surgery was the only independently associated factor with long-term mortality [HR (95% CI) 1.59 (0.77-3.28) for SOFA 5-9; 3.56 (1.71-7.38) for SOFA 10-14; 11.58 (4.02-33.35) for SOFA 15-20; reference category SOFA 0-4; P < 0.0001]. Surgical timing was not associated with post-operative outcomes. Of the 158 patients with a theoretical indication for surgery, the 58 deemed not fit had a 95% mortality rate.
Mortality in patients with critical IE remains unacceptably high. Factors associated with long-term outcomes are the severity of multiorgan failure, prosthetic mechanical valve IE, vegetation size ≥15 mm, and surgical treatment. Up to one-third of potential candidates do not undergo surgery and these patients experience extremely high mortality rates. The strongest independent predictor of post-operative mortality is the pre-operative multiorgan failure score while surgical timing does not seem to impact on outcomes.
评估重症左侧感染性心内膜炎（IE）的长期预后和治疗管理，并评估手术的影响。
在法国 33 个成人重症监护病房（ICU）中，前瞻性纳入了 198 例 IE 患者，从 2007 年 4 月 1 日至 2008 年 10 月 1 日进行监测，中位随访时间为 59.5 个月。与死亡率显著相关的特征包括：ICU 入院时的脓毒症相关器官衰竭评估（SOFA）评分[风险比（HR），95%置信区间（CI）为 0.79-2.59 ；1.05-3.85；1.75-7.11；参考类别为 SOFA 0-4；P=0.003]；人工机械性心脏瓣膜 IE[HR 2.01；95%CI 1.09-3.69；P=0.025]；赘生物大小≥15mm[HR 1.64；95%CI 1.03-2.63；P=0.038]；以及心脏手术[HR（95%CI），手术距 IE 诊断≤1 天为 0.33（0.16-0.67）；手术距 IE 诊断 2-7 天为 0.61（0.29-1.26）；手术距 IE 诊断>7 天为 0.42（0.21-0.83）；参考类别为无手术；P=0.005]。103 例（52%）患者在 IE 诊断后中位时间 6（16）天接受了心脏手术。多变量分析的独立手术干预预测因素为：年龄≤60 岁[比值比（OR）5.30；95%CI（2.46-11.41）；P<0.01]，心力衰竭[OR 3.27；95%CI（1.03-10.35）；P=0.04]，心源性休克[OR 3.31；95%CI（1.47-7.46）；P=0.004]，感染性休克[OR 0.25；95%CI（0.11-0.59）；P=0.002]，免疫抑制[OR 0.15；95%CI（0.04-0.55）；P=0.004]，以及 ICU 入院前或 24 小时内诊断[OR 2.81；95%CI（1.14-6.95）；P=0.025]。手术当天计算的 SOFA 评分是与长期死亡率唯一相关的独立因素[HR（95%CI）为 SOFA 5-9 为 1.59（0.77-3.28）；SOFA 10-14 为 3.56（1.71-7.38）；SOFA 15-20 为 11.58（4.02-33.35）；参考类别为 SOFA 0-4；P<0.0001]。手术时机与术后结局无关。在 158 例有理论手术适应证的患者中，58 例认为不适合手术的患者死亡率为 95%。
重症 IE 患者的死亡率仍然高得令人无法接受。与长期预后相关的因素包括多器官衰竭的严重程度、人工机械性心脏瓣膜 IE、赘生物大小≥15mm 以及手术治疗。多达三分之一的潜在手术候选者未接受手术，这些患者的死亡率极高。术后死亡率的最强独立预测因素是术前多器官衰竭评分，而手术时机似乎对结局没有影响。
