Wilson W R, Geraci J E
Herz. 1983 Dec;8(6):332-43.
Since the introduction of effective antimicrobial therapy, the leading cause of death in patients with infective endocarditis is no longer sepsis but, rather, congestive heart failure. The mortality is higher in patients with severe heart failure due to infective endocarditis who are treated with medical therapy only than in those who additionally undergo cardiac valve replacement. The mortality is also higher in patients with severe heart failure due to aortic infective endocarditis (40 to 93%) than in those with heart failure due to mitral infective endocarditis (17 to 66%). In patients with and in those without infective endocarditis, surgical intervention can be carried out with comparable mortality not only for aortic valve replacement (9 vs 8.4%) but also overall for valve replacement (10 vs 12%). In patients with class IV heart failure, overall mortality of valve replacement was higher (17%) than in patients with class II (8%) or class III heart failure (7%) and, similarly, comparable with that of matched groups of patients without infective endocarditis. In patients with class IV disability, the mortality of valve replacement was higher in those with active infective endocarditis (19%) than in those with inactive infective endocarditis, possibly due to a higher incidence of sudden onset of severe aortic regurgitation and myocardial abscess. No patient with valve replacement for inactive infective endocarditis developed prosthetic valve endocarditis; a single case of prosthetic valve endocarditis occurred in a patient with active infective endocarditis. In general, early surgical intervention is preferable to procrastination in the management of patients with progressive or severe heart failure due to infective endocarditis. Although, in at least 70% of patients, blood cultures may be rendered sterile within one week of initiation of appropriate antimicrobial therapy, patients with infective endocarditis due to staphylococci, multiply-resistant gram-negative bacilli, fungi, Q-fever or those with myocardial abscess or multiple relapses may require surgical intervention. While the overall incidence of clinically apparent emboli has been reported to be as high as 30%, in a ten-year observation period at the Mayo Clinic, the rate was 5.6%. Patients with echocardiographic evidence of large or mobile vegetations and those with infective endocarditis cause by microorganisms associated with a high risk of embolization such as slow-growing fastidious gram-negative bacilli, fungi (especially Aspergillus) and nutritionally-variant viridans streptococci should be considered candidates for surgery irrespective of a history of emboli.(ABSTRACT TRUNCATED AT 400 WORDS)
自从引入有效的抗菌治疗以来，感染性心内膜炎患者的主要死亡原因已不再是败血症，而是充血性心力衰竭。仅接受药物治疗的感染性心内膜炎所致严重心力衰竭患者的死亡率高于那些同时接受心脏瓣膜置换术的患者。主动脉感染性心内膜炎所致严重心力衰竭患者的死亡率（40%至93%）也高于二尖瓣感染性心内膜炎所致心力衰竭患者（17%至66%）。在有和没有感染性心内膜炎的患者中，不仅主动脉瓣置换术的手术干预死亡率相当（9%对8.4%），而且总体瓣膜置换术的死亡率也相当（10%对12%）。在IV级心力衰竭患者中，瓣膜置换术的总体死亡率（17%）高于II级（8%）或III级心力衰竭患者（7%），同样，与无感染性心内膜炎的匹配患者组相当。在IV级残疾患者中，有活动性感染性心内膜炎的患者瓣膜置换术的死亡率（19%）高于无活动性感染性心内膜炎的患者，这可能是由于严重主动脉反流和心肌脓肿突然发作的发生率较高。无活动性感染性心内膜炎而进行瓣膜置换术的患者未发生人工瓣膜心内膜炎；1例人工瓣膜心内膜炎发生在有活动性感染性心内膜炎的患者中。一般来说，在感染性心内膜炎所致进行性或严重心力衰竭患者的管理中，早期手术干预优于拖延。虽然，在至少70%的患者中，在开始适当的抗菌治疗后一周内血培养可能转阴，但由葡萄球菌、多重耐药革兰氏阴性杆菌、真菌、Q热引起的感染性心内膜炎患者，或有心肌脓肿或多次复发的患者可能需要手术干预。虽然据报道临床上明显栓塞的总体发生率高达30%，但在梅奥诊所的十年观察期内，发生率为5.6%。有超声心动图证据显示有大的或活动的赘生物的患者，以及由与栓塞高风险相关的微生物引起感染性心内膜炎的患者，如生长缓慢的苛养革兰氏阴性杆菌、真菌（尤其是曲霉菌）和营养变异型草绿色链球菌，无论有无栓塞史，都应被视为手术候选者。（摘要截于400字）
