左心细菌性感染性心内膜炎手术适应证中仅以 vegetation 大小作为手术指征的再评估。

Reassessment of Vegetation Size as a Sole Indication for Surgery in Left-Sided Infective Endocarditis.

机构信息

Instituto de Ciencias del Corazón, Hospital Clínico, Ciber de enfermedades cardiovasculares, Valladolid, Spain.

出版信息

J Am Soc Echocardiogr. 2022 Jun;35(6):570-575. doi: 10.1016/j.echo.2021.12.013. Epub 2021 Dec 28.

DOI:10.1016/j.echo.2021.12.013

PMID:34971762

Abstract

BACKGROUND

Guidelines recommend surgery for left-sided infective endocarditis (LSIE) that is associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome.

METHODS

A total of 726 patients with definitive LSIE were included in our analysis. The mean age was 64.9 years, and 61% were male. Multivariate analysis of all patients was performed to determine whether vegetation size is related to death in LSIE. Then patients were divided into two groups according to vegetation size: group A (>10 mm, n = 420) and group B (≤10 mm, n = 306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. The impact of surgery on mortality in group A patients without heart failure or uncontrolled local infection (n = 139) was assessed.

RESULTS

Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure, and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B; P = .045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%; P = .678), stroke (22% vs 17.0%, P = .091), systemic embolism (39% vs 32%; P = .074), perivalvular complication (28% vs 28%; P = .865), and septic shock (15% vs 13%; P = .288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection, mortality was similar with and without surgery (n = 139; n = 70 with surgery and n = 69 without surgery; mortality, 18.6% vs 11.6%, respectively; P = .251).

CONCLUSIONS

Large vegetations identify patients with poor outcomes in the context of LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

摘要

背景

指南建议对左侧感染性心内膜炎（LSIE）合并大赘生物进行手术治疗。鉴于大多数接受手术的患者也有其他适应证（心力衰竭和/或感染未得到控制），对于没有其他不良预后预测因素的大赘生物患者，是否应常规推荐手术仍存在争议。

方法

本研究共纳入 726 例明确的 LSIE 患者。患者平均年龄为 64.9 岁，61%为男性。对所有患者进行多变量分析，以确定赘生物大小与 LSIE 患者死亡是否相关。然后根据赘生物大小将患者分为两组：A 组（＞10mm，n=420）和 B 组（≤10mm，n=306）。对 A 组患者进行单变量和多变量分析，以确定与该组患者死亡相关的变量。评估无心力衰竭或未控制局部感染的 A 组患者（n=139）手术对死亡率的影响。

结果

年龄、金黄色葡萄球菌、瓣周并发症、心力衰竭、肾衰竭和感染性休克与死亡相关，而赘生物大小与死亡无关。大赘生物患者死亡率增加（A 组为 31.7%，B 组为 24.8%；P=0.045）。A 组比 B 组更易发生瓣叶破裂和瓣叶反流，但心力衰竭（55%比 53%；P=0.678）、脑卒中（22%比 17.0%；P=0.091）、全身栓塞（39%比 32%；P=0.074）、瓣周并发症（28%比 28%；P=0.865）和感染性休克（15%比 13%；P=0.288）在两组间无差异。在无心力衰竭或未控制感染的 A 组患者中，手术与非手术患者的死亡率相似（n=139；n=70 例手术患者，n=69 例非手术患者；死亡率分别为 18.6%和 11.6%；P=0.251）。