复杂性感染性心内膜炎的外科治疗

Surgical interventions for complex native valve endocarditis

目的 评价瓣周脓肿、心肌脓肿以及瓣膜严重毁损等复杂性感染性心内膜炎手术治疗的近、远期疗效。方法 回顾性分析 1988年 12月至 2 0 0 2年 6月手术治疗的复杂性心内膜炎患者 5 7例临床资料 ,均为原发性心内膜炎 ,其中感染侵犯主动脉瓣 2 5例、二尖瓣 16例、二尖瓣和主动脉瓣16例。术中发现瓣叶严重毁损 32例、主动脉瓣周脓肿 19例、主动脉根部环形脓肿导致左心室 主动脉连接破坏 4例、二尖瓣后瓣环脓肿 11例、心肌脓肿 6例、瓣膜赘生物形成 5 5例。脓肿清除后遗留残腔采用间断褥式缝合 6例、自体心包片修补 19例、牛心包片修补 6例、聚四氟乙烯膨体补片修补 4例 ;施行以带瓣管道作升主动脉根部替换和左、右冠状动脉移植术 4例 ,主动脉瓣替换术 2 1例 ,二尖瓣替换术 16例 ,主动脉瓣及二尖瓣双瓣替换术 16例。结果 早期死亡 6例 (11% ) ,死亡主要原因为低心输出量综合征、人造心脏瓣膜性心内膜炎和多脏器功能衰竭。随访 4个月至 14年 ,平均 (5 93±0 2 0 )年。晚期死亡 5例 ,晚期主要并发症为人造瓣膜性心内膜炎。术后 1年心功能恢复NYHA分组Ⅰ～Ⅱ级占 96 % (44 / 4 6 ) ;5年再手术免除率为 (84± 3) % ,5年实际生存率为 (6 1± 9) %。结论 复杂性心内膜炎局部组织破坏较多 ,应限期手术或急症手?

Objective To elucidate the early and long term results of surgical treatment for complex infective endocarditis with prosthetic valve replacement. Methods Fifty seven patients of complex native valve endocarditis, including 25 cases of aortic valve, 16 of mitral valve and 16 of double valves, who underwent operative interventions with prosthetic valve replacement between December 1988 and June 2002, were analyzed retrospectively. Intraoperative findings demonstrated aortic annular abscesses ( n =19), root abscesses ( n =4), mitral posterior annular abscesses ( n =11), myocardial abscesses ( n =6), massive leaflet destruction ( n =32) and valvular vegetations ( n =55). Complex reconstruction of the aortic and mitral annulus was required in 35 patients. Associated procedures included Bentall′s procedure ( n =4), aortic valve replacement ( n =21), mitral valve replacement ( n =16) and double valve replacements ( n =16). Results The operative mortality was 11%. Complications included low cardiac output syndrome, recurrence of endocarditis, multiple organ failure, ventricular arrhythmia, bleeding, mediastinal infection, respiratory insufficiency and heart block. Follow up was 100% complete at a mean of 5 93 years. There were five late deaths (3 prosthetic valve endocarditis, 2 valve related). The NYHA functional status recovered to Class Ⅰ in 17 patients, Class Ⅱ in 27 and Class Ⅲ in 2 at 1 year follow up. Kaplan Meier analysis showed the 5 year actuarial freedom from reoperation was (84±3)%, and actuarial survivorship at 5 years was (61±9)%. Conclusions Urgent or even emergency operation is advocated for complex infective endocarditis. Proper intraoperative reconstruction of the aortic and mitral annulus and optimized perioperative management, especially the strategy for prevention of recurrent endocarditis, are of great importance in achieving satisfied early and long term clinical outcomes.