Division of Cardiovascular and Perioperative Medicine.
Division of Cardiovascular and Perioperative Medicine.
Eur J Intern Med. 2020 Aug;78:82-87. doi: 10.1016/j.ejim.2020.04.017. Epub 2020 Apr 18.
In patients with left-sided infective endocarditis (IE) and heart failure associated with large vegetations, early surgery prevents embolic events. However, optimal timing of surgery for other indications is still unresolved particularly when the presence of large vegetations represents the sole indication.
We retrospectively analyzed 308 consecutive patients admitted to our department with definite left-sided IE. Of these patients, 243 (79%) underwent cardiac surgery (complicated IE), 34 patients with uncomplicated IE received medical treatment, 24 were not operated due to prohibitive general conditions and 7 refused surgery. Long-term follow-up was obtained by structured telephone interviews.
During the 6-year follow-up (average 121.8 weeks ± 76), patients not operated because of general conditions or refusal had the worst prognosis, while outcome in operated patients for complicated IE was comparable to that of uncomplicated IE treated medically. Early (<2 weeks from diagnosis) surgery was associated with better survival compared to delayed surgery (HR 0.58, p = 0.23). Embolic events were detected at admission in 38% of cases; Staphylococcus Aureus etiology and vegetation size were independently associated with embolism (OR 2.4, p = 0.01; OR 1, p=0.008 respectively).
Compared to uncomplicated medically-treated patients, complicated IE showed comparable survival when managed aggressively by surgical intervention, whereas a conservative approach was associated with an adverse prognosis. Staphylococcus Aureus infection and vegetation size were independent predictors of systemic embolism. Our data support aggressive surgical management of complicated IE patients and highlight the importance of etiological characterization in clinical decision-making.
对于左侧感染性心内膜炎（IE）合并心力衰竭且伴有大赘生物的患者，早期手术可预防栓塞事件。然而，对于其他适应证，手术的最佳时机仍未确定，尤其是当大赘生物是唯一适应证时。
我们回顾性分析了我院收治的 308 例确诊为左侧 IE 的连续患者。其中 243 例（79%）接受了心脏手术（复杂 IE），34 例单纯 IE 患者接受了药物治疗，24 例因一般情况不佳而未手术，7 例拒绝手术。通过结构化电话访谈获得长期随访结果。
在 6 年的随访期内（平均 121.8 周±76 周），因一般情况或拒绝手术的患者预后最差，而接受复杂 IE 手术的患者的结局与接受药物治疗的单纯 IE 患者相似。早期（从诊断到手术的时间<2 周）手术与晚期手术相比，存活率更高（HR 0.58，p=0.23）。38%的病例在入院时即发现有栓塞事件；金黄色葡萄球菌感染和赘生物大小与栓塞事件独立相关（OR 2.4，p=0.01；OR 1，p=0.008）。
与单纯药物治疗的患者相比，积极进行手术干预可使复杂 IE 患者获得相似的生存率，而保守治疗则与不良预后相关。金黄色葡萄球菌感染和赘生物大小是全身栓塞的独立预测因子。我们的数据支持对复杂 IE 患者进行积极的手术治疗，并强调了在临床决策中对病因学特征进行评估的重要性。
