Surgical timing in infective endocarditis complicated by intracranial hemorrhage.
Surgical timing in infective endocarditis complicated by intracranial hemorrhage.
复制标题
感染性心内膜炎并发颅内出血的手术时机。
DOI：
10.1016/j.ahj.2019.07.011
复制
发表时间：
2019
影响因子：
4.8
通讯作者：
Wasfy,JasonH
中科院分区：
文献类型：
--
作者：
Venn,RachaelA;Ning,MingMing;Vlahakes,GusJ;Wasfy,JasonH
鉴于感染性心内膜炎（IE）的发病率不断增加，了解瓣膜手术的风险和受益至关重要。对于1/10的并发颅内出血（ICH）的病例，这一决定尤其复杂。虽然指南建议目前一般倾向于早期手术，但仍建议ICH患者延迟干预至少4周。到目前为止，还没有随机对照试验告知有手术适应症但伴随ICH的患者的管理，甚至报告的观察性数据也很罕见。本文回顾了目前关于手术时机的文献，特别关注ICH病例。它强调了越来越多的文献挑战了当前的范式，即4周内手术与神经系统恶化和高死亡率相关，证明了接受早期瓣膜手术的术前ICH患者的良好结局。基于这些数据，我们提出了一个实用的管理算法，以方便在这些复杂的情况下决定手术时机。由于可能永远无法获得更严格的证据，临床医生应根据患者的具体情况做出手术时机决定，以平衡神经系统与心脏并发症的竞争风险。
Given the growing incidence of infective endocarditis (IE), understanding the risks and benefits of valvular surgery is critical. This decision is particularly complex for the 1 in 10 cases complicated by intracranial hemorrhage (ICH). While guideline recommendations currently favor early surgery in general, delayed intervention of at least 4 weeks is still recommended for patients with ICH. To date, there are no randomized controlled trials that inform management of patients with an indication for surgery but concomitant ICH, and even reported observational data are rare. This paper reviews the current literature on timing of surgery with a specific focus on cases of ICH. It emphasizes a growing body of literature challenging the current paradigm that surgery within 4 weeks is associated with neurologic deterioration and high mortality rates by demonstrating favorable outcomes for patients with pre-operative ICH who undergo early valvular surgery. Based on these data, we propose a practical management algorithm to facilitate decisions on surgical timing in these complicated cases. Since more rigorous evidence may never be available, clinicians should make patient-specific surgical timing decisions that attempt to balance the competing risks of neurologic versus cardiac complications.