Eishi K, Kawazoe K, Kuriyama Y, Kitoh Y, Kawashima Y, Omae T
Division of Cardiovascular Surgery, National Cardiovascular Center of Japan, Osaka, Japan.
J Thorac Cardiovasc Surg. 1995 Dec;110(6):1745-55. doi: 10.1016/S0022-5223(95)70038-2.
To establish guidelines for the surgical treatment of patients with infective endocarditis who have cerebrovascular complications, we conducted a detailed retrospective study of 181 of 244 patients with cerebral complications among 2523 surgical cases of infective endocarditis of the Japanese Association of Thoracic Surgery. The results showed that 9.7% of all patients with infective endocarditis had associated cerebral complications: 108 (44.3%) had active native valve endocarditis, 96 (39.3%) had healed native valve endocarditis, and 40 (16.4%) had prosthetic valve endocarditis. The hospital mortality of the patients with cerebral complications was 11.0% in the group as a whole: 13.9% in active native valve endocarditis, 3.1% in healed native valve endocarditis, and 37.5% in prosthetic valve endocarditis. Diseased valves included the following aortic valve in 55.5%, mitral valve 49.8%, tricuspid valve in 1.3%, and pulmonary valve in 1.3%. In 181 patients with cerebral complications, organisms were detected as follows: gram-positive cocci in 133 (73.5% [Streptococcus in 85, Staphylococcus in 32]), gram-negative in 18 (9.9%), fungus in 11 (6.1%), and unknown in 64.6%, cerebral bleeding in 31.5%, cerebral abscess in 2.8%, and meningitis in 1.1%. Hospital mortality rate and an exacerbation rate of cerebral complications, including related death, according to the interval from onset of cerebral infarction to cardiac surgery, were as follows: 66.3% and 45.5% within 24 hours, 31.3% and 43.8% between 2 and 7 days, 16.7% and 16.7% between 8 and 14 days, 10.0% and 10.0% between 15 and 21 days, 26.3% and 10.5% between 22 and 28 days, and 7.0% and 2.3% over 4 weeks later, respectively. A significant correlation existed between the interval and the exacerbation of cerebral complications (tied p = 0.008). Preoperative risk factors affecting exacerbation of cerebral complications were as follows: (1) severity of cerebral complications (p = 0.006), (2) intervals (p = 0.012), and (3) uncontrolled congestive heart failure as indications for cardiac surgery (p = 0.014). One patient underwent a cardiac operation within 24 hours of the onset of cerebral hemorrhage and died of cerebral damage. No exacerbations occurred in 10 patients who underwent their operation between 2 and 28 days. Nevertheless, exacerbations occurred in 19.0% of patients whose operation was done more than 4 weeks later. These data suggest that cardiac operations can be done safely 4 weeks after cerebral infarction, and if the delay is more than 2 weeks, the exacerbation rate will be around 10%. The risk of progression of cerebral damage is still significant 15 days and even 4 weeks after cerebral hemorrhage.
为制定感染性心内膜炎合并脑血管并发症患者的外科治疗指南，我们对日本胸外科学会2523例感染性心内膜炎外科病例中的244例合并脑并发症患者中的181例进行了详细的回顾性研究。结果显示，所有感染性心内膜炎患者中有9.7%合并脑并发症：108例（44.3%）为活动性自体瓣膜心内膜炎，96例（39.3%）为愈合的自体瓣膜心内膜炎，40例（16.4%）为人工瓣膜心内膜炎。合并脑并发症患者的总体医院死亡率为11.0%：活动性自体瓣膜心内膜炎患者为13.9%，愈合的自体瓣膜心内膜炎患者为3.1%，人工瓣膜心内膜炎患者为37.5%。病变瓣膜情况如下：主动脉瓣占55.5%，二尖瓣占49.8%，三尖瓣占1.3%，肺动脉瓣占1.3%。181例合并脑并发症的患者中，检测到的病原体如下：革兰氏阳性球菌133例（73.5%[85例为链球菌，32例为葡萄球菌]），革兰氏阴性菌18例（9.9%），真菌11例（6.1%），不明病原体64.6%，脑出血31.5%，脑脓肿2.8%，脑膜炎1.1%。根据脑梗死发作至心脏手术的间隔时间，脑并发症（包括相关死亡）的医院死亡率和恶化率如下：24小时内为66.3%和45.5%，2至7天为31.3%和43.8%，8至14天为16.7%和16.7%，15至21天为10.0%和10.0%，22至28天为26.3%和10.5%，4周后为7.0%和2.3%。间隔时间与脑并发症恶化之间存在显著相关性（t检验p值=*** 0.008）。影响脑并发症恶化的术前危险因素如下：（1）脑并发症的严重程度（p值=0.006），（2）间隔时间（p值=0.012），以及（3）作为心脏手术指征的未控制的充血性心力衰竭（p值=0.014）。1例患者在脑出血发作后24小时内接受心脏手术，死于脑损伤。10例在2至28天内接受手术的患者未发生恶化。然而，手术在4周后进行的患者中有19.0%发生恶化。这些数据表明，脑梗死4周后可安全进行心脏手术，如果延迟超过2周，恶化率约为10%。脑出血后15天甚至4周，脑损伤进展的风险仍然很大。
