Schulz R, Werner G S, Fuchs J B, Andreas S, Prange H, Ruschewski W, Kreuzer H
Department of Cardiology, Georg-August-University, Göttingen, Germany.
Eur Heart J. 1996 Feb;17(2):281-8. doi: 10.1093/oxfordjournals.eurheartj.a014846.
Prosthetic valve endocarditis is considered to be associated with a more severe prognosis than native valve endocarditis. Among other factors, inappropriate visualization of vegetations in prosthetic valve endocarditis by transthoracic echocardiography is responsible for this observation. Since the introduction of transoesophageal echocardiography into clinical practice the diagnostic sensitivity and specificity of the detection of vegetations located on prosthetic valves have been enhanced. Therefore we aimed to determine and compare the prognosis of prosthetic valve endocarditis and native valve endocarditis in the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104 patients were seen at our institution between 1989 and 1993. Eighty patients (77%) had native valve endocarditis and 24 (23%) had late prosthetic valve endocarditis. In the latter group two patients had recurrent infective endocarditis. Patients with prosthetic valve endocarditis were older (mean age 64 vs 54 years in native valve endocarditis; P < 0.001) and the majority was female (62% vs 38% in native valve endocarditis; P < 0.05). In prosthetic valve endocarditis, infection of a valve in the mitral position predominated (65% vs 30% in native valve endocarditis; P < 0.01), whereas in native valve endocarditis more than half the cases had isolated aortic valve endocarditis (51% vs 27% in prosthetic valve endocarditis; P < 0.01). In prosthetic valve endocarditis more cases were caused by Staphylococcus aureus (31% vs 14% in native valve endocarditis; P = 0.08), whereas in native valve endocarditis the most frequent organisms were streptococci (29% vs 19% in prosthetic valve endocarditis; P = 0.12). Differences in the clinical features of native valve endocarditis and prosthetic valve endocarditis could not be found except for a higher rate of embolism in native valve endocarditis (40% vs 19% in prosthetic valve endocarditis; P < 0.05). Vegetations could be detected by transthoracic echocardiography more frequently in native valve endocarditis (71% vs 15% in prosthetic valve endocarditis; P < 0.0001). Transoesophageal echocardiography visualized vegetations in 95% of the episodes of native valve endocarditis and in 80% of the episodes of prosthetic valve endocarditis (P = 0.09). Thus, the diagnostic gain by transoesophageal echocardiography was greatest in prosthetic valve endocarditis. Patients with native valve endocarditis had significantly larger vegetations than patients with prosthetic valve endocarditis (P < 0.05 for length, P < 0.001 for width). The median time to diagnosis was similar in native valve endocarditis and prosthetic valve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditis and in 58% of those with prosthetic valve endocarditis; the median time delay between the diagnosis of infective endocarditis and surgery tended to be shorter in prosthetic valve endocarditis than in native valve endocarditis (45 vs 60 days). The in-hospital mortality and the mortality during a follow-up of 22 +/- 10 months did not significantly differ between native valve endocarditis and prosthetic valve endocarditis (21% vs 17%; 28% vs 25%). In summary in the era of transoesophageal echocardiography, late prosthetic valve endocarditis does not seem to carry a worse prognosis than native valve endocarditis. This can be attributed in part to the improved diagnostic accuracy achieved by transoesophageal echocardiography leading to comparable diagnostic latency periods in both patient groups. Finally, better characterization of vegetations on prosthetic valves by transoesophageal echocardiography allows early lifesaving surgery in patients with prosthetic valve endocarditis.
人工瓣膜心内膜炎被认为比自体瓣膜心内膜炎的预后更严重。在其他因素中，经胸超声心动图对人工瓣膜心内膜炎赘生物的显示不充分是导致这一观察结果的原因。自从经食管超声心动图应用于临床实践以来，人工瓣膜上赘生物检测的诊断敏感性和特异性都有所提高。因此，我们旨在确定并比较在这种改进的诊断方法时代，人工瓣膜心内膜炎和自体瓣膜心内膜炎的预后。1989年至1993年间，我们机构共收治了104例患者的106次感染性心内膜炎发作。80例患者（77%）患有自体瓣膜心内膜炎，24例患者（23%）患有晚期人工瓣膜心内膜炎。在后一组中，有2例患者发生了复发性感染性心内膜炎。人工瓣膜心内膜炎患者年龄更大（平均年龄64岁，自体瓣膜心内膜炎患者为54岁；P<0.001），且大多数为女性（62%，自体瓣膜心内膜炎患者为38%；P<0.05）。在人工瓣膜心内膜炎中，二尖瓣位瓣膜感染占主导（65%，自体瓣膜心内膜炎为30%；P<0.01），而在自体瓣膜心内膜炎中，超过半数病例为孤立性主动脉瓣心内膜炎（51%，人工瓣膜心内膜炎为27%；P<0.01）。人工瓣膜心内膜炎更多病例由金黄色葡萄球菌引起（31%，自体瓣膜心内膜炎为14%；P=0.08），而在自体瓣膜心内膜炎中最常见的病原体是链球菌（29%，人工瓣膜心内膜炎为19%；P=0.12）。除了自体瓣膜心内膜炎的栓塞发生率更高（40%，人工瓣膜心内膜炎为19%；P<0.05）外，未发现自体瓣膜心内膜炎和人工瓣膜心内膜炎临床特征的差异。经胸超声心动图在自体瓣膜心内膜炎中更频繁地检测到赘生物（71%，人工瓣膜心内膜炎为15%；P<0.0001）。经食管超声心动图在95%的自体瓣膜心内膜炎发作和80%的人工瓣膜心内膜炎发作中显示出赘生物（P=0.09）。因此，经食管超声心动图在人工瓣膜心内膜炎中的诊断增益最大。自体瓣膜心内膜炎患者的赘生物明显大于人工瓣膜心内膜炎患者（长度P<0.05，宽度P<0.001）。自体瓣膜心内膜炎和人工瓣膜心内膜炎的诊断中位时间相似（31天对28天）。74%的自体瓣膜心内膜炎患者和58%的人工瓣膜心内膜炎患者接受了手术；人工瓣膜心内膜炎从感染性心内膜炎诊断到手术的中位时间延迟往往比自体瓣膜心内膜炎短（45天对60天）。自体瓣膜心内膜炎和人工瓣膜心内膜炎的住院死亡率以及22±10个月随访期间的死亡率无显著差异（21%对17%；28%对25%）。总之，在经食管超声心动图时代，晚期人工瓣膜心内膜炎的预后似乎并不比自体瓣膜心内膜炎更差。这部分归因于经食管超声心动图提高了诊断准确性，使两组患者的诊断潜伏期相当。最后，经食管超声心动图对人工瓣膜上赘生物的更好特征描述使得人工瓣膜心内膜炎患者能够早期接受挽救生命的手术。
