Wilbring Manuel, Irmscher Linda, Alexiou Konstantin, Matschke Klaus, Tugtekin Sems-Malte
Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
Interact Cardiovasc Thorac Surg. 2014 Jun;18(6):740-7. doi: 10.1093/icvts/ivu039. Epub 2014 Mar 4.
Infective native valve endocarditis (NVE) complicated by a preoperative neurological event still remains a surgical challenge. Particularly, great uncertainty exists with regard to the optimal timing of surgery. We call for a multidisciplinary team approach for individualized risk estimation and analysed our experience obtained over the past decade.
Between 1997 and 2012, a total of 495 patients underwent valve surgery for the treatment of NVE. Of these, 70 (14.1%) patients suffered from NVE complicated by an acute neurological event and formed the study group. The remaining 425 (85.9%) patients served as the control group. The mean age of the predominantly male (80.0%) study population was 54 ± 14 years. EuroSCORE and EuroSCORE II predicted a high surgical risk (24.9 ± 6.8 and 10.8 ± 8.1%, respectively). The mean follow-up time was 4.0 ± 3.1 years, ranging up to 15.6 years with an interquartile range from 1.7 to 5.4 years. An interdisciplinary team consisting of a cardiac surgeon, a cardiologist and a neurologist made the decision for surgery.
Observed neurological deficits mainly consisted of ischaemic stroke (75.7%), meningoencephalitis (12.9%) and intracerebral haemorrhage (8.6%). The mean time interval between the neurological event and surgery was 8.7 ± 10.3 days for all patients, 8.0 ± 7.0 days for ischaemic stroke and 17 ± 24 days for intracerebral haemorrhage. Postoperatively, most of the patients experienced no change (22.9%) or even improvement (67.1%) of their neurological symptoms. Only 10.0% showed further deterioration of their neurological status. This was particularly true for patients suffering from intracerebral haemorrhage, with 33.3% experiencing further neurological impairment. The presence of a preoperative neurological event was identified as an independent risk factor for in-hospital mortality (OR 2.66; 95% CI: 1.02-6.78; P = 0.046) but not for mortality during further follow-up (P = 0.257). The hospital mortality rate was 17.2%; and the 1-, 5- and 10-year survival rates were 74.3, 68 ± 5.0 and 67.1 ± 9.0%, respectively.
NVE complicated by neurological events remains a challenging disease with high mortality and morbidity. Cardiac surgery seemed to be safe in the observed time interval, particularly for patients suffering from ischaemic stroke. A multidisciplinary approach is advocated for very individualized risk estimation.
感染性原发性瓣膜心内膜炎（NVE）合并术前神经系统事件仍然是一项外科挑战。特别是，手术的最佳时机存在很大不确定性。我们呼吁采用多学科团队方法进行个体化风险评估，并分析了我们在过去十年中获得的经验。
1997年至2012年期间，共有495例患者接受了瓣膜手术以治疗NVE。其中，70例（14.1%）患者患有NVE并合并急性神经系统事件，组成研究组。其余425例（85.9%）患者作为对照组。以男性为主（80.0%）的研究人群平均年龄为54±14岁。欧洲心脏手术风险评估系统（EuroSCORE）和欧洲心脏手术风险评估系统二代（EuroSCORE II）预测手术风险较高（分别为24.9±6.8%和10.8±8.1%）。平均随访时间为4.0±3.1年，最长达15.6年，四分位间距为1.7至5.4年。由心脏外科医生、心脏病专家和神经科医生组成的跨学科团队做出手术决策。
观察到的神经功能缺损主要包括缺血性卒中（75.7%）、脑膜脑炎（12.9%）和脑出血（8.6%）。所有患者神经事件与手术之间的平均时间间隔为8.7±10.3天，缺血性卒中患者为8.0±7.0天，脑出血患者为17±24天。术后，大多数患者神经症状无变化（22.9%）甚至改善（67.1%）。只有10.0%的患者神经状态进一步恶化。脑出血患者尤其如此，33.3%的患者神经功能进一步受损。术前神经系统事件的存在被确定为住院死亡率的独立危险因素（比值比2.66；95%置信区间：1.02 - 6.78；P = 0.046），但不是进一步随访期间死亡率的独立危险因素（P = 0.257）。医院死亡率为17.2%；1年、5年和10年生存率分别为74.3%、68±5.0%和67.1±9.0%。
合并神经系统事件的NVE仍然是一种具有高死亡率和高发病率的挑战性疾病。在所观察的时间间隔内，心脏手术似乎是安全的，特别是对于缺血性卒中患者。提倡采用多学科方法进行非常个体化的风险评估。
