Iaccarino Alessandra, Barbone Alessandro, Basciu Alessio, Cuko Enea, Droandi Ginevra, Galbiati Denise, Romano Giorgio, Citterio Enrico, Fumero Andrea, Scarfò Iside, Manzo Rossella, La Canna Giovanni, Torracca Lucia
Cardiovascular Department, UO of Cardiac Surgery of IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy.
Cardiovascular Department, Applied Diagnostic Echocardiography of IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy.
J Clin Med. 2023 Sep 11;12(18):5891. doi: 10.3390/jcm12185891.
Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.
尽管感染性心内膜炎（IE）在临床、微生物学、影像学及治疗方面已发生了深刻变化，但其仍是一种危及生命的疾病，致死率较高。如今，由于风湿热发病率下降，IE的发病情况已有所改变，但另一方面，老年人群、心血管装置植入手术、多种影像学检查手段的更好应用以及多学科护理等多个因素增多，导致诊断率上升。自欧洲心脏病学会（ESC）和美国心脏协会（AHA）发布指南以来，诊断和治疗管理的具体方面已得到明确，以实现更快速、准确的诊断及更好的预后。约半数IE患者需要接受手术治疗，以避免进展为心力衰竭、在感染无法控制时避免不可逆的结构损伤以及预防栓塞。手术时机一直是讨论的主要方面之一，需要确定哪些情况需进行急诊手术（24小时内）或紧急手术（7天内），而不论抗生素治疗的时长，以及哪些情况可推迟手术以便在仔细的临床和超声心动图观察下进行短期抗生素治疗。指南主要强调了心内膜炎治疗团队在处理全身并发症以及这些并发症如何影响手术时机和围手术期管理方面的重要性。神经系统并发症、急性肾衰竭、脾脏或肌肉骨骼表现，或由多重耐药微生物或真菌引起的感染，都会影响长期预后和生存率。同样重要的还有解剖和手术因素，如自体瓣膜或人工瓣膜心内膜炎的存在、可行时的修复策略、环形脓肿（二尖瓣环、主动脉二尖瓣间隔、主动脉根部和瓣环）情况下的解剖扩展和破坏，以及假体和导管的选择。外科医生在正确的术前规划与术中应对意外障碍之间可能会面临困难。本综述的目的是概述和分析一系列广泛的特定手术场景，以及具有挑战性的管理方法如何对确保更好的治疗效果和预后至关重要。
