先心病并发细菌性心内膜炎的外科治疗

Clinical Characteristics and Surgical Treatment of Congenital Heart Diseases Complicated by Bacterial Endocarditis

对１８例先天性心脏畸形并发细菌性心内膜炎病人进行直视心脏手术，其中１３例在感染控制后手术，５例于感染活动期行限期或急症手术。感染病灶主要在左心系统者５例，其中３例主动脉瓣叶破坏行瓣膜替换，２例二尖瓣大瓣腱索断裂行腱索移植和瓣环成形。病灶主要在右心系统者１３例，剔除或切除病变组织和赘生物并行三尖瓣修复５例，带单瓣人工血管片加宽右室流出道１例。所有先天性心脏畸形均同期处理。手术死亡１例，死亡率５．６％。本组资料表明：先心病并发细菌性心内膜炎者感染病灶多在右心系统，常伴肺部感染，应积极控制感染和尽早手术，于彻底清除病灶同时矫治先天性心脏畸形；对损毁瓣膜尽可能采用修复术。术后选用抗生素的种类和疗程应根据不同病情而区别对待。

Eighteen patients with congenital heart diseases (CHD)complicated by the bacterial endocarditis were treated surgically under cardiopulmonary bypass(CPB).The operations were done in 13 cases after the infection was controlled, and in the other 2,during acute or subacute phase,While the infection could not be fully controlled.The infective foci were located mainly in the left heart in 5(27.78%).In 3 of them,the aortic valve was so damaged the valve replcement was mandatory;in the other 2 cases,the ruptured chordae tendinae of the anterior leaflet of the mitral valves were repaired using the chordae tendinae transplantation and annuloplasty was added.When the infective foci were located mainly in rights hearts(n=13 72.22%),through debridement or piercing up of the foci and vegetations was performed together with tricuspid valvuloplasty in 5 cases,and resection of the pulmonary leaflets plus enlargement of the right ventricular outflow tract by using a patch with monocuspid in 1.All congenital cardiac defects were treated simultaneously.One patient died with a mortality of 5.6%.The present data suggest that:in congenital heart diseases complicated with bacterial endocarditis,approximately 3/4 of the infective foci located in the right heart and usually induced refractory pneumonia.The therapeutic strategy must be actively and completely to control the infection if possble and to perform the operation as early as possible.Simultaneous repair of the CHD is necessary in order to reduce the heart loading and lessen the chance of recurrence of infection.Valvuloplasty through eradication or debridement of the infective foci is the key step to lay down the base for a sueressful control of infective endocarditis postoperatively.valvuloplasty would be preferable for the atrioven tricular valve lesion.Postoperative selection and therapeutic course of antibiotics must depend on the variant pathological characteristics in each patient.