Department of Thoracic and Cardiovascular Surgery Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio.
Ann Thorac Surg. 2022 Feb;113(2):535-543. doi: 10.1016/j.athoracsur.2021.03.072. Epub 2021 Apr 8.
Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. This study aimed to characterize further the invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression.
A total of 43 patients with invasive aortic valve IE were prospectively enrolled from August 2017 to July 2018. Of these patients, 23 (53%) had prosthetic valve IE, 2 (5%) had allograft IE, and 18 (42%) had native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin fixed and analyzed histologically. The time course of disease and management were evaluated.
Pathogens included Staphylococcus aureus in 17 patients (40%). Invasion predominantly affected the non-left coronary commissure (76%) and was circumferential in 15 patients (35%) (14 had prosthetic valves). Extraaortic cellulitis was present in 29 patients (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulas. Histopathologic examination revealed acute inflammation, abscess formation, and lysis of connective tissue but not of myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. Patients with S aureus had a 21-day shorter time course than patients non-S aureus. New or worsening heart block developed in 8 patients.
Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, including pathogen, time, and host immune response, and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions.
主动脉瓣感染性心内膜炎（IE）进展并破坏瓣叶以外区域即为侵袭性 IE，其特征尚未完全阐明。本研究旨在进一步描述侵袭性疾病的范围、部位和阶段，并将大体手术所见与微观疾病模式和进展相关联。
2017 年 8 月至 2018 年 7 月前瞻性纳入 43 例侵袭性主动脉瓣 IE 患者。其中 23 例（53%）为人工瓣膜 IE，2 例（5%）为同种异体移植瓣膜 IE，18 例（42%）为原生主动脉瓣 IE。分析手术发现和术中摄影，以明确侵袭部位、范围和阶段。手术标本福尔马林固定并进行组织学分析。评估疾病的时间进程和治疗方法。
病原体包括 17 例金黄色葡萄球菌（40%）。侵袭主要累及非左冠状动脉瓣环（76%），15 例（35%）为环周（14 例为人工瓣膜）。29 例（67%）存在主动脉瓣周蜂窝织炎，13 例（30%）存在脓肿，29 例（67%）存在脓肿腔，8 例（19%）存在假性动脉瘤；7 例（16%）存在瘘管。组织病理学检查显示急性炎症、脓肿形成和结缔组织溶解，但未累及心肌或弹性组织。从症状发作到使用抗生素的中位时间为 5 天，侵袭确认的中位时间为 15 天，手术的中位时间为 37 天。金黄色葡萄球菌组的病程比非金黄色葡萄球菌组短 21 天。8 例患者新发或恶化的心脏传导阻滞。
晚期侵袭性主动脉瓣 IE 具有一致的大体模式和阶段，与组织病理学发现相关。侵袭由多种因素共同作用所致，包括病原体、时间和宿主免疫反应，主要累及心脏的纤维骨架，并向低压区域扩展。
