Sáez Carmen, Sarriá Cristina, Vilacosta Isidre, Olmos Carmen, López Javier, García-Granja Pablo Elpidio, Fernández Cristina, de Las Cuevas Carmen, Reyes Guillermo, Domínguez Lourdes, San Román Jose Alberto
Department of Medicine-Infectious diseases, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Spain.
Instituto Cardiovascular. Hospital Universitario Clínico San Carlos, Madrid, Spain.
Medicine (Baltimore). 2019 Aug;98(35):e16903. doi: 10.1097/MD.0000000000016903.
Staphylococcus aureus prosthetic valve endocarditis (SAPVE) has a poor prognosis. There are no large series that accurately describe this entity.This is a retrospective observational study on a prospective cohort from 3 Spanish reference hospitals for cardiac surgery, including 78 definitive episodes of left SAPVE between 1996 and 2016.Fifty percent had a Charlson Index score >5; 53% were health care-related. Twenty percent did not present fever. Complications at diagnosis included: severe heart failure (HF, 29%), septic shock (SS, 17.9%), central nervous system abnormalities (19%), septic metastasis (4%). Hemorrhagic stroke was not higher in anticoagulated patients. Twenty-seven percent were methicilin-resistant SA (MRSA). Fifteen of 31 had positive valve culture; it was related to surgery within first 24 hours. At diagnosis, 69% had vegetation (>10 mm in 75%), 21.8% perianular extension, and 20% prosthetic dehiscence. Forty-eight percent had persistent bacteremia, related to nonsurgical treatment. Perianular extension progressed in 18%. Surgery was performed in 35 episodes (12 with stroke). Eleven uncomplicated episodes were managed with medical therapy, 8 survived. In-hospital mortality was 55%, higher in episodes with hemorrhagic stroke (77.8% vs 52.2%, odds ratio 3.2 [0.62-16.55]). Early SAPVE was nosocomial (92%), presented as severe HF (54%), patients were diagnosed and operated on early, 38% died. In intermediate SAPVE (9 weeks-1 year) diagnosis was delayed (24%), patients presented with constitutional syndrome (18%), renal failure (41%), and underwent surgery >72 hours after indication; 53% died. Late SAPVE (>1 year) was related with health care, diagnosis delay, and 60% of deceases.Left SAPVE frequently affected patients with comorbidity and health care contact. Complications at diagnosis and absence of fever were frequent. Presence of MRSA was high. Positive valve culture was related to early surgery. Paravalvular extension was frequent; vegetations were large, but its absence at diagnosis was common. Some uncomplicated SAPVE episodes were safety treated with medical therapy. Surgery was feasible in patients with stroke. Mortality was high. There were differences in some clinical characteristics and in evolution according to the time elapsed from valve replacement. Prognosis was better in early SAPVE.
金黄色葡萄球菌人工瓣膜心内膜炎（SAPVE）预后较差。目前尚无大量准确描述该疾病实体的系列研究。这是一项对来自3家西班牙心脏外科参考医院的前瞻性队列进行的回顾性观察研究，纳入了1996年至2016年间78例确诊的左心SAPVE病例。50%的患者Charlson指数评分>5；53%与医疗保健相关。20%的患者无发热表现。诊断时的并发症包括：严重心力衰竭（HF，29%）、感染性休克（SS，17.9%）、中枢神经系统异常（19%）、感染性转移（4%）。抗凝患者的出血性卒中发生率并不更高。27%为耐甲氧西林金黄色葡萄球菌（MRSA）。31例中有15例瓣膜培养阳性；与术后24小时内的手术相关。诊断时，69%有赘生物（75%的赘生物>10mm），21.8%有瓣周扩展，20%有人工瓣膜裂开。48%有持续性菌血症，与非手术治疗有关。18%的患者瓣周扩展有进展。35例进行了手术（12例合并卒中）。11例无并发症的病例采用药物治疗，8例存活。住院死亡率为55%，出血性卒中患者的死亡率更高（77.8%对52.2%，优势比3.2[0.62 - 16.55]）。早期SAPVE多为医院获得性（92%），表现为严重HF（54%），患者诊断和手术较早，38%死亡。中期SAPVE（9周 - 1年）诊断延迟（24%），患者出现全身症状（18%）、肾衰竭（41%），在有手术指征后>72小时才进行手术；53%死亡。晚期SAPVE（>1年）与医疗保健、诊断延迟有关，60%的患者死亡。左心SAPVE常累及有合并症和有医疗保健接触史的患者。诊断时并发症常见且无发热表现。MRSA感染率高。瓣膜培养阳性与早期手术有关。瓣周扩展常见；赘生物较大，但诊断时无赘生物也很常见。一些无并发症的SAPVE病例采用药物治疗安全有效。合并卒中的患者手术可行。死亡率高。根据瓣膜置换后的时间不同，一些临床特征和病情演变存在差异。早期SAPVE的预后较好。
