单纯累及右心系统的感染性心内膜炎的外科治疗

Surgical treatment of isolated right-sided infective endocarditis

目的 评价单纯右心系统受累的感染性心内膜炎的外科治疗效果.方法 回顾性分析2003年1月至2013年7月间连续手术治疗的45例单纯累及右心系统的心内膜炎患者,平均年龄（38.5±14.7）岁,其中男性24例,女性21例.28例患者合并先天性心脏畸形,3例有永久起搏器电极,14例患者未合并心脏畸形,1例患者有静脉注射毒品史.术前心功能（NYHA分级）Ⅱ级13例、Ⅲ级30例、Ⅳ级2例.手术清除心内赘生物、修补合并的心内畸形、行三尖瓣修复31例,三尖瓣置换3例,肺动脉瓣修复10例.主动脉阻断（65.5±34.4）min,体外循环时间（95.6±46.7）min.结果 术后平均住ICU时间（3.8±2.7）d.术后再次开胸止血1例,呼吸功能不全4例,肾功能不全8例,切口裂开1例.无住院死亡.随访（3.9±2.4）年,心功能Ⅰ～Ⅱ级,2例出现三尖瓣中度反流,1例肺动脉瓣中度反流.结论 右心感染性心内膜炎合并基础心脏疾病、药物治疗效果不佳或者高侵袭性病原菌感染患者,早期积极手术治疗可以取得满意的效果.

Objective To study the efficacy of surgical treatment for isolated right-sided infective endocarditis.Methods Clinical data of 45 patients with right-sided infective endocarditis who consecutively underwent cardiovascular operations between 2003 and 2013 were analyzed retrospectively.There were 24 males and 21 females,mean age was （38.5±14.7）years.28 patients had congenital cardiovascular anomaly,3 had permanent intracardiac pacing wires,and 14 had no pre-existing cardiac anomaly.One patient was intravenous drug user.There were 13,30 and 2 patients in NYHA functional class Ⅱ,Ⅲ and Ⅳ respectively.Complete debridement was first achieved during the operation,and congenital defect was repaired accordingly.Tricuspid repair or reconstruction was achieved in 31 patients,tricuspid replacement was performed in 31 patients and pulmonary valve repair was performed in 10 patients.Mean aortic clamp time was （65.5±34.4）minutes,and mean cardiopulmonary bypass time was （95.6±46.7）minutes.Results Mean ICU stay was （3.8±2.7）days.Post-operative bleeding requiring reexploration occurred in 1 patient,acute respiratory distress in 4 patients and transient renal impairment in 8 patients.No in-hospital death was observed.Patients were followed up for （3.9±2.4）years.All were in NYHA Ⅰ or Ⅱ functional class.Two patients presented with moderate tricuspid incompetence and one presented with moderate pulmonary incompetence.Conclusion The results of our study clearly demonstrate that in patients with isolated right-sided infective endocarditis,surgical intervention yields excellent early and midterm results with majority of patients benefit from reconstructive techniques.Complete debridement and valvular competence and should be considered as the ultimate goal of surgical treatment.