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感染性心内膜炎伴深静脉血栓形成护理一例

以脾梗死为首发的感染性心内膜炎误诊一例

120例感染性心内膜炎的外科治疗

目的总结 120例感染性心内膜炎（ IE）的围术期处理经验，探讨手术时机和方法。方法回顾性分析华中科技大学附属协和医院 2006年 1月至 2011年 4月 120例感染性心内膜炎患者接受手术治疗的临床资料，男 75例，女 45例；年龄 4～ 73（44±3）岁。以发热为主就诊 36例，术前心功能不全 54例，脑栓塞 10例，血培养阳性 20例，超声心动图证实心内有赘生物形成 111例。所有患者均在体外循环下进行赘生物清除、心瓣膜置换术及原发心脏病矫正手术。术后继续使用抗生素治疗 4～ 6周。结果全组患者术后住院时间 14～ 60（20±6）d，无手术死亡。全组术后死亡 5例；生存出院 115例，出院患者随访 3个月～ 4年，均恢复良好。术后发生并发症 20例，再次手术患者 2例。结论感染性心内膜炎应做到早发现、早诊断、早治疗，并掌握好手术时机和原则，恰当的围手术期处理，可取得良好的效果。

心源性脑栓塞患者的心瓣膜置换术

摘要： 目的 [HTSS]探讨心源性脑栓塞患者行心瓣膜置换术的手术时机、疗效，总结围手术期处理经验。 方法 回顾性分析1999年6月至2008年10月42例心源性脑栓塞患者接受心瓣膜置换术的临床资料，男25例，女17例；年龄28~64岁，平均年龄45.5岁；病程0.5~30.0年。风湿性心脏病31 例，感染性心内膜炎11 例；行二尖瓣置换术27例，主动脉瓣置换术11例，二尖瓣和主动脉瓣联合瓣膜置换术4例；同期行三尖瓣成形术18例，左心房血栓清除术22例。 结果 术后早期（30 d内）死亡4例，手术死亡率9.52%；其中死于鱼精蛋白过敏、严重肺部感染、急性肾功能衰竭、脑出血和广泛脑栓塞各1例；其余患者均顺利出院，术后平均住院时间为12.5 d。随访35例，随访时间2~112个月，随访期间死亡5例，其中1例术后1个月余因头部外伤致颅内出血死亡，1例3年后死于脑出血，1例5年后死于肺癌， 2例6年后死于心力衰竭；其余患者生存状况良好。失访3例。 结论 心源性脑栓塞患者行心瓣膜置换术效果良好，应根据心瓣膜病变程度、心功能状况以及脑栓塞的程度决定手术时机。脑栓塞后有以下情况者可尽早手术治疗：（1）急性心力衰竭、心功能Ⅳ级，经内科保守治疗效果不佳；（2）梗塞灶小，偏瘫轻，或偏瘫后恢复快；（3）伴左心房血栓或心瓣膜赘生物，短期内可能再次栓塞者。加强围手术期处理是手术成功的重要因素。

Diagnosis and Treatment for Prosthetic Valve Endocarditis

Abstract: Objective To summarize the experiences of treatment for prosthetic valve endocarditis (PVE), paying special emphasis on some interrelated conceptions of PVE, its microbiology, diagnosis, prevention and treatment. Methods From September 1979 to September 2009, 33 patients diagnosed to have PVE were treated in our department. There were 17 males and 16 females. Their age ranged from 19 to 57 years old with an average age of 34 years. The incidence of PVE was 1.48% （33/2 236）including 1.03%（16/1 551）, 3.00%（7/233）, 2.28%（10/438）, and 0% of PVE in mitral valve replacement (MVR), aortic valve replacement (AVR), double valve replacement (DVR), tricuspid valve replacement (TVR), respectively. Pure medical treatment (Penicillin or Vancomycin with other broadspectrum antibiotics, Fluconazole and Amphotericin) was performed on 22 patients. Combined medical and surgical treatment was performed in 11 patients. The patients underwent operation after adequate antibiotics treatment and general condition improvement. The infective tissue and vegetation were completely debrided after the infective prosthetic valve was removed. Before the new valve was transplanted, paravalvular tissue was cleaned with antibiotics, iodine solution and normal saline. Results Hospital death occurred in 19 patients (86.36%) and only 3 patients (13.64%) recovered in the group with pure medical treatment. The main reasons for death were infective shock and cardiac failure in 9 patients, and cerebral complications including embolism, bleeding and multipleorgan failure in 10 patients. For the group with combined medical and surgical treatment, 10 patients (90.91%) survived and only one patient (9.09%) died of multipleorgan failure. Follow-up was done in 13 patients for 6 months to 15 years averaging 41 months. During the follow-up, only one patient was reoperated because of the paravalvular leak eight year later. There was no PVE recurrence in all the rest patients. Conclusion Compared with pure medical treatment, combined medical and surgical treatment is a better solution for PVE.

Retrospective study of the diagnosis and treatment of culture-negative aortic infective endocarditis

ObjectiveTo discuss the diagnosis and treatment of culture-negative aortic infective endocarditis.MethodsThe clinical data of 73 patients with infective endocarditis of the aortic valve whose results of bacteria culture were negative from January 2013 to January 2018 were retrospectively analyzed, including 59 males and 14 females aged 14-71 (39.2±14.8) years.ResultsSixty seven (91.8%) patients received aortic valve replacement, 2 (2.7%) patients received the second operation in hospital, and 12 (16.4%) patients had concomitant mitral valvuloplasty. In-hospital death occurred in 8 (11.0%) patients. Postoperatively, 11 (20.7%) patients had a low cardiac output and 4 (11.0%) patients had heart block, and 1 patient required implantation of a permanent pacemaker. The 1- and 5- year survival rates were 92.3%±2.3% and 84.5%±4.5%, respectively.ConclusionThere are difficulties in the diagnosis and treatment of culture-negative infective endocarditis. Most of the affected patients are in a healed status, which could be a cause of negative culture results. In-hospital mortality in the patients is associated with a history of previous cardiac surgery, whereas the long-term survival rate is good for the patients after surgery.

Mitral Valvuloplasty for the Treatment of Infective Endocarditis and Mitral Regurgitation

ObjectiveTo investigate clinical outcomes of mitral valvuloplasty (MVP)for the treatment of infective endocarditis (IE)and mitral regurgitation (MR). MethodsFrom March 2002 to January 2012, 33 patients with IE and MR underwent MVP in Fu Wai Hospital. There were 23 male and 10 female patients with their age of 10-67 (35.7±17.8)years. Thirteen patients had previous cardiac anomalies. Preoperatively, there were 5 patients with mild MR, 15 patients with moderate MR and 13 patients with severe MR. There were 5 patients in New York Heart Association (NYHA)functional classⅠ, 23 patients in classⅡ, 4 patients in classⅢ and 1 patient in classⅣ. All the patients received MVP including 14 patients received MVP in active phase of IE. Concomitantly, 6 patients received aortic valve replacement, 5 patients received tricuspid valvuloplasty, 1 patient received coronary artery bypass grafting, 1 patient received resection of left atrial myxoma and 1 patient received repair of aortic sinus aneurysm. Surgical procedures included pericardial patch closure of leaflet perforation in 5 patients, leaflet excision and suturing in 17 patients, double-orifice method in 3 patients, chordae transfer and artificial chordae implantation in 5 patients, and annuloplastic ring implantation in 15 patients. ResultsOne patient died of acute myocardial infarction 7 days after the operation. All other 32 patients were successfully discharged. Echocardiography before discharge showed left ventricular end-diastolic diameter (LVEDD, 48.9±7.6 mm)and left atrial diameter (LAD, 31.7±7.4 mm)were significantly smaller than preoperative values (P=0.000). Thirty-two patients were followed up for 6-125 (73.0±38.6)months. There was no death, IE recurrence, bleeding or thromboembolism during follow-up. One patient received mitral valve replacement for mitral stenosis 3 years after discharge. There were 25 patients in NYHA func-tional classⅠ, 5 patients in classⅡand 2 patients in classⅢ. There were 4 patients with mild MR, 1 patient with moderate MR, and 26 patients had no MR. One patient had faster mitral inflow at diastolic phase (1.7 m/s). One patient had moderate aortic regurgitation. LVEDD and LAD during follow-up were not statistically different from those before discharge. Left ventricular ejection fraction during follow-up was significantly higher than that before discharge (60.9%±6.6% vs. 57.5%±6.7%, P=0.043). ConclusionMVP is a reliable surgical procedure for patients with IE and MR, and can significantly reduce left atrial and left ventricular diameter and improve cardiac function postoperatively.

Research progress of mitral valvuloplasty in patients with infective endocarditis

Infective endocarditis is one of the severest valvar diseases, commonly affecting the mitral valve. Currently, valvuloplasty and replacement are the main surgical options for mitral infective endocarditis. However, the complexity of the infectious lesions has caused a raging debate on which surgical approach offers more benefits. With the development of surgical treatment for endocarditis, mitral valvuloplasty may be a superior solution. It can preserve the integrity of the valve structure, avoiding complications caused by replacement. However, there is a lack of evidence from randomized clinical trials and other evidence-based medical supports. Furthermore, issues regarding the timing of surgery, repair methods, and material choices for mitral valvuloplasty in these patients have not been standardized. Therefore, this article summarizes existing literature to assist clinicians in making appropriate treatment decisions.

Surgical Treatment and Clinical Diagnosis of Infective Endocarditis: Report of 60 Cases

Abstract： Objective To summarize the clinical diagnostic and therapeutic experiences of infective endocarditis (IE). Methods From Jan. 2000 to Aug. 2006，60 IE patients underwent heart operation in PLA General Hospital. There were 46 male and 14 female patients, with an average age of 34.3 years old. Blood culture was positive in 25 cases (41.7%), Streptococcus was found in 12 cases, Staphylococcus in 6 cases and other bacteria in 7 cases. Ultrasonic cardiography(UCG) revealed vegetations or valve perforation in 42 cases, including 26 aortic valves, 9 mitral valves and 6 double valves. 28 cases had primary cardiac diseases，including 16 cases of congenital heart anomalies，9 cases of rheumatic heart disease and 3 cases of mitral valve prolapse. High dose of sensitive antibiotics were utilized all through the treatment in all IE patients. There were 55 selective surgeries and 5 emergent ones. Infected tissues were debrided radically，intracardiac malformation was corrected in 16 cases, valve replacement was performed in 41 cases, tricuspid plasty in 1 case. Results There were 3 patients of earlydeath. 51 patients(89.5%) were followedup for 5-71 months with norecurrence. Postoperative cardiac function (NYHA): class I was in 38 cases, class II in 13 cases. Conclusion Early diagnosis, optimal surgical timing, combined internal medicine and surgical treatment provided good therapeutic effect of IE.

Diagnosis and treatment of ventricular septal defect with infective endocarditis in 40 patients

ObjectiveTo analyze the diagnosis and treatment of patients with ventricular septal defect complicated with infective endocarditis.MethodsWe retrospectively analyzed the clinical data of 40 patients with ventricular septal defect complicated with infective endocarditis in our hospital from 2001 to 2016. There were 25 males and 15 females, aged 20-62 (39.92±11.16) years. They were divided into two groups according to the duration from admission to surgery: a group A (an early operation group whose surgery was performed within 7 days after admission) and a group B (a conventional treatment group with the duration from admission to surgery>7 days). Among them, there were 27 patients in the group A including 15 males and 12 females with an average age of 39.56±11.80 years, and 13 patients in the group B including 10 males and 3 females with an average age of 40.69±10.13 years. All patients were examined by echocardiogram and blood bacterial culture to investigate their etiology, echocardiogram results and treatment status. And the clinical data of the two groups were compared.ResultsTwo patients died before operation in the group B, one died of heart failure, and one cerebral infarction. No reoperation during hospitalization, cerebral infarction, thromboembolism or other complications occurred. The ventilation time in the group A was significantly shorter than that in the group B (18.00±14.85 h vs. 31.00±29.57 h, P=0.015). There was no statistical difference in the extracorporeal circulation time, myocardial block time, or postoperative hospital stay between the two groups (P>0.05). After discharge, the patients continued antibiotic therapy for 3-6 weeks. Patients were followed up for 12-127 (75.74±6.01) months, 1 died of malignant tumors in the group A, 1 developed atrial fibrillation and 1 developed cardiac insufficiency in the group B, and the rest of patients did not complain of obvious discomfort. There was no residual shunt, recurrence of infective endocarditis, reoperation, postoperative stroke or thromboembolism.ConclusionPreoperative echocardiography and blood bacteriological culture are helpful for the diagnosis and treatment of patients with ventricular septal defect complicated with infective endocarditis. Early surgery is safe and effective for these patients, and can improve the long-term survival rate.