右侧感染性心内膜炎的外科治疗。

Surgical treatment of right-sided infective endocarditis.

机构信息

Education Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio.

Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery.

出版信息

J Thorac Cardiovasc Surg. 2019 Apr;157(4):1418-1427.e14. doi: 10.1016/j.jtcvs.2018.07.112. Epub 2018 Sep 25.

DOI:10.1016/j.jtcvs.2018.07.112

PMID:30503743

Abstract

OBJECTIVE

Right-sided infective endocarditis is increasing because of increasing prevalence of predisposing conditions, and the role and outcomes of surgery are unclear. We therefore investigated the surgical outcomes for right-sided infective endocarditis.

METHODS

From January 2002 to January 2015, 134 adults underwent surgery for right-sided infective endocarditis. Patients were grouped according to predisposing condition. Hospital outcomes, time-related death, and reoperation for infective endocarditis were analyzed.

RESULTS

A total of 127 patients (95%) had tricuspid valve and 7 patients (5%) pulmonary valve infective endocarditis; 66 patients (49%) had isolated right-sided infective endocarditis, and 68 patients (51%) had right- and left-sided infective endocarditis. Predisposing conditions included injection drug use (30%), cardiac implantable devices (26%), chronic vascular access (19%), and other/none (25%). One native tricuspid valve was excised, 76% were repaired or reconstructed, and 23% were replaced. Intensive care unit and postoperative hospital stays were similar among groups. Injection drug users had the best early survival (no hospital mortality), and patients with chronic vascular access had the worst late survival (18% at 5 years). Survival was worst for concomitant mitral valve versus isolated right-sided infective endocarditis or concomitant aortic valve infective endocarditis. Survival after tricuspid valve replacement was worse than after repair/reconstruction. Estimated glomerular filtration rate was the strongest risk factor for death, not predisposing condition. Eleven patients underwent 12 reoperations for infective endocarditis; more reoperations occurred in injection drug users (P = .03).

CONCLUSIONS

Overall outcomes after surgery are variable and affected by patient condition, not predisposing condition. Injection drug use carries a higher risk of reoperation for infective endocarditis. Earlier surgery may permit more valve repairs and improve outcomes. Whenever possible, tricuspid valve replacement should be avoided.

摘要

目的

由于易患疾病的增加，右侧感染性心内膜炎的发病率不断上升，而手术的作用和结果尚不清楚。因此，我们研究了右侧感染性心内膜炎的手术治疗效果。

方法

2002 年 1 月至 2015 年 1 月，共有 134 名成人因右侧感染性心内膜炎接受手术治疗。根据易患疾病的不同对患者进行分组。分析了住院结果、与时间相关的死亡率以及因感染性心内膜炎再次手术的情况。

结果

共有 127 例（95%）患者为三尖瓣感染性心内膜炎，7 例（5%）患者为肺动脉瓣感染性心内膜炎；66 例（49%）患者为单纯右侧感染性心内膜炎，68 例（51%）患者为右侧和左侧感染性心内膜炎。易患疾病包括注射吸毒（30%）、心脏植入装置（26%）、慢性血管通路（19%）和其他/无（25%）。1 例患者的原生三尖瓣被切除，76%的患者接受了修复或重建，23%的患者接受了置换。各组患者在重症监护病房和术后住院时间方面无显著差异。注射吸毒者的早期存活率（无院内死亡率）最高，慢性血管通路患者的晚期存活率（5 年时 18%）最差。同时合并二尖瓣病变的患者比单纯右侧感染性心内膜炎或同时合并主动脉瓣感染性心内膜炎患者的存活率更差。三尖瓣置换术后的存活率低于修复/重建术后。估计肾小球滤过率是死亡的最强危险因素，而不是易患疾病。11 例患者因感染性心内膜炎进行了 12 次再次手术；注射吸毒者的再次手术次数更多（P=0.03）。