Muehrcke D D, Lytle B W, Cosgrove D M
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
Ann Thorac Surg. 1995 Sep;60(3):538-43. doi: 10.1016/0003-4975(95)00469-2.
Fungal prosthetic valve endocarditis is an uncommon but serious disease. We have developed a strategy of treatment that includes perioperative amphotericin B, radical debridement of infected tissue, reconstruction using biologic tissue when possible, and prolonged oral suppressive antifungal therapy.
We retrospectively reviewed the charts of 12 patients reoperated on for fungal prosthetic valve endocarditis involving the aortic valve (10 patients: six porcine valves, two mechanical valves, two homografts) and the mitral valve (2 patients, both porcine valves). Prosthetic valve endocarditis developed in 7 within 12 months after the first valve procedure. The organisms included Candida species (9 patients), Scopulariopsis brevicaulis (1), Saccharomyces cervisiae (1), and histoplasmosis (1).
At operation, all patients had prosthetic vegetations, 8 had abscesses, and 4 had sinus tracts. Seven received aortic homografts, 4 received porcine valves (two mitral), and 1 received a mechanical prosthesis. Two patients died in the hospital after prolonged illnesses (83% hospital survival). Four patients had recurrence an average of 25 months later and 3 underwent further surgical intervention. One patient had recurrence and died 17 months postoperatively. One other late death occurred 96 months after operation, and there was no evidence of recurrence. Eight patients (67%) are alive and well 51.5 +/- 61.0 months (range, 1 to 189 months) after the first redo procedure for fungal prosthetic valve endocarditis.
We conclude that preoperative treatment with amphotericin B, radical resection of all infected tissue, cardiac reconstruction using biologic tissue when possible, and life-long oral antifungal therapy is effective for fungal prosthetic valve endocarditis.
真菌性人工瓣膜心内膜炎是一种罕见但严重的疾病。我们制定了一种治疗策略，包括围手术期使用两性霉素B、对感染组织进行彻底清创、尽可能使用生物组织进行重建以及长期口服抗真菌抑制治疗。
我们回顾性分析了12例因真菌性人工瓣膜心内膜炎接受再次手术患者的病历，其中主动脉瓣受累10例（6个猪瓣膜、2个机械瓣膜、2个同种异体移植物），二尖瓣受累2例（均为猪瓣膜）。7例人工瓣膜心内膜炎发生在首次瓣膜手术后12个月内。病原体包括念珠菌属（9例）、短帚霉（1例）、酿酒酵母（1例）和组织胞浆菌病（1例）。
手术时，所有患者均有赘生物，8例有脓肿，4例有窦道。7例接受了主动脉同种异体移植物，4例接受了猪瓣膜（2例二尖瓣），1例接受了机械瓣膜假体。2例患者在长期患病后死于医院（医院生存率83%）。4例患者平均在25个月后复发，3例接受了进一步的手术干预。1例患者复发并在术后17个月死亡。另1例晚期死亡发生在术后96个月，无复发证据。8例患者（67%）在因真菌性人工瓣膜心内膜炎首次再次手术后51.5±61.0个月（范围1至189个月）存活且状况良好。
我们得出结论，术前使用两性霉素B治疗、彻底切除所有感染组织、尽可能使用生物组织进行心脏重建以及终身口服抗真菌治疗对真菌性人工瓣膜心内膜炎有效。
