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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

Advances in diagnosis and surgical treatment of infective endocarditis

Infective endocarditis (IE) is a disease with severe complications and high mortality. It is heterogeneous in etiology, clinical manifestations, and course. At the same time, there are many disputes on the clinical practice of antibiotic treatment, surgical indications and timing. In this review, we discuss the epidemiology, diagnosis, treatment, and prevention of IE, especially the latest advances in surgical treatment after the release of European Society of Cardiology and American Heart Association guidelines in 2015.

感染性心内膜炎临床护理

【摘要】感染性心内膜炎（infective endoearditis，IE）是一种严重威胁人类健康及生命的疾病，可导致心力衰竭、栓塞及心律失常等并发症，有较高的死亡率。对IE患者进行全面细致的护理及指导，强化健康教育，可减少相关并发症的发生，缩短住院时间，降低死亡率，从而改善患者的预后。

二尖瓣脱垂合并感染性心内膜炎的临床分析

目的 总结二尖瓣脱垂(mitral valve prolapse，MVP)合并感染性心内膜炎(infectous endocarditis,IE)的临床特点、手术时机和手术前后超声心动图的特点。 方法 2000年6月至2007年12月我科共收治原发性MVP合并IE患者45例，术前心功能分级(NYHA)Ⅱ级15例，Ⅲ级21例，Ⅳ级9例。术前血培养阳性率为40％，最常见的为草绿色链球菌(38.9％)。术前超声心动图检查发现腱索断裂3例，急性左心功能衰竭9例，有脑血管意外6例。术中根据瓣膜质量和损伤情况，行二尖瓣成形术5例，二尖瓣置换术35例；同期行主动脉瓣置换术6例，三尖瓣成形术19例，冠状动脉旁路移植术1例。 结果 术前死亡5例，3例死于脑血管意外，2例死于多器官功能衰竭；术后早期死亡1例，死于肾功能衰竭；长期生存39例，术后随访6个月～8年(平均2.7年)，无晚期死亡，超声心动图复查未见心内膜炎复发及瓣周漏。 结论 MVP合并IE的临床特点为起病隐匿，心力衰竭、体循环栓塞(尤其脑栓塞)等并发症的发生率较高。对中至重度关闭不全的MVP合并IE患者应早期治疗。

Influence of Early Surgery on the Outcome of Infective Endocarditis

ObjectiveTo study the relationship between the timing of surgery and one-year outcome in patients with infective endocarditis. MethodsWe retrospectively analyzed the clinical data of 97 patients suffered from leftside native valve infective endocarditis with neoplasm, admitted in Shanghai First People's Hospital between January 2000 and December 2011. There were 65 males and 32 females with mean age of 55.2±16.3 years (ranged 29 to 75 years). They were divided into two groups according to whether the surgery was performed within a week after diagnosis. The in-hospital mortality and one-year mortality, embolism and re-infection were calculated and compared between the two groups. ResultsThere was no significant difference in the in-hospital mortality between the early surgery group and the conventional surgery group (1.9% versus 6.7%, P=0.241). While there was a significant difference in the rate of inhospital embolism related complications (1.9% versus 13.3%, P=0.030) between the two groups. There was no significant difference in one-year mortality between the two groups (1.9% versus 8.9%, P=0.122). The incidence rate of embolism related complication was 5.8% in the early surgery group and 20.0% in the conventional surgery group with a statistical difference (P=0.034). There was one patient with recurrent cerebral infarction among the 11 patients of cerebral infarction in the early surgery group,while 6 recurrent patients in the 9 patients with cerebral infarction in the conventional surgery group (9.1% versus 66.7%, P<0.005). ConclusionsEarly surgery in patients with left-side native valve infective endocarditis can't reduce the in-hospital mortality and one-year mortality but does decrease embolic events significantly. Early surgery is feasible in the patients with cerebral infarction.

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。

Operative Opportunity for Active Infective Endocarditis

【摘要】　目的　探讨活动期感染性心内膜炎（infectiue endocarditis，IE）患者心脏手术的最佳时期。　方法　回顾分析1999年9月-2009年9月行外科治疗的92例IE患者的临床资料。IE诊断标准为修订的Duke标准。采用SPSS 12.0软件包，分析了年龄、性别、是否是院内感染IE、合并症（糖尿病、慢性阻塞性肿疾病、癌症）、病原菌、手术时间等因素与手术并发症及6个月病死率的关系。　结果　56例患者在确诊为IE后7 d内手术，36例患者在确诊7 d后，并抗生素治疗完成后手术。葡萄球菌为主要感染菌株，与栓塞、脓肿及感染性休克显著相关。最常见的手术指征是重度的瓣膜关闭不全合并心功能不全。6个月的病死率为12%。早期手术与晚期手术比较，病死率增高。单因素分析显示，与6个月病死率相关的因素包括葡萄球菌感染和感染性休克。多因素分析显示感染性休克为6个月内死亡的预测因子。感染性休克的患者尽管行了早期手术，病死率仍为67%。严重瓣膜关闭不全的患者，若未出现心衰，无手术（早期或晚期）死亡。　结论　手术患者的预后由是否发生过感染性休克决定。晚期手术组患者结果好于早期手术组，但结果的差异可能并不是手术的时期不同，而是感染性心内膜炎的严重程度不同造成的。对于有重度瓣膜返流但无心衰的患者，早期手术可能在缩短住院时间，预防心衰发生上有帮助。【Abstract】　Objective　To discuss the optimal time of cardiac operations in patients with infective endocarditis (IE).　Methods　We analyzed the clinical data of 92 patients with IE diagnosed by the modified Duke criteria between September 1999 and September 2009. SPSS 12.0 was used to analyze predictors of 6-month mortality, including age, sex, nosocomial origin of infection, comorbid conditions (diabetes, chromic obstructive pulmonary disease, cancer), the causative microorganisms, the timing of cardiac operation, and the complications.　Results　Fifty-six patients underwent operation within the first 7 days after diagnosis of infective endocarditis, and 36 received operation at the completion of antibiotic treatment 7 days after the diagnosis. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 12%. Early operation showed an increased mortality compared with late operation. Univariate analysis showed that factors associated with 6-month mortality included staphylococci infection and septic shock. Multivariate analysis revealed that septic shock was a predictor of 6-month mortality. Despite early operation for patients with septic shock, 67% of them died. No death occurred to patients with severe regurgitation but without heart failure after undergoing (early or late) operations.　Conclusions　The prognosis for surgically treated patients is determined by the occurrence of septic shock. The outcome in patients undergoing late operations is favorable compared with patients undergoing early operations. This difference is probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefits in shortening the length of hospitalization and preventing development of heart failure.

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。

先天性心脏病合并感染性心内膜炎的外科治疗

目的 总结先天性心脏病（congenital heart disease，CHD）合并感染性心内膜炎（infective endocarditis，IE）的外科治疗经验，以提高诊断、治疗效果。 .方法 .回顾性分析我院73例CHD合并IE患者行瓣膜手术的临床资料，对30例主动脉瓣感染性心内膜炎者行主动脉瓣置换术，另3例行Ross手术。在IE累及二尖瓣21例患者中，行二尖瓣成形术5例，二尖瓣置换术16例；10例主动脉瓣、二尖瓣IE行双瓣膜置换术；对6例肺动脉瓣IE患者行单瓣法做肺动脉瓣成形术2例，肺动脉瓣置换术4例，其中1例同期行主动脉弓置换；3例三尖瓣IE均行三尖瓣置换术。结果 主动脉瓣感染33例(45.2％)，二尖瓣感染21例(28.8％)，肺动脉瓣感染6例(8.2％)，双瓣膜感染10例(13.7％)，三尖瓣感染3例(4.1％)。血培养及赘生物培养总阳性率为23.3％，其中链球菌8例（47.1％），葡萄球菌3例（17.6％）。本组无手术死亡，除1例二尖瓣置换术后1年再次发生IE，拒绝手术治疗外，其余72例患者随访1年均治愈。 结论 CHD应尽早行根治性手术，以避免远期并发IE，损坏心脏瓣膜。对CHD合并IE出现瓣膜关闭不全者应尽快手术，如IE累及二尖瓣、三尖瓣且无瓣膜结构的严重损毁者，施行瓣膜成形术是较好的方法。