Complications of infective endocarditis.
Complications of infective endocarditis.
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感染性心内膜炎的并发症。
DOI：
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发表时间：
2009
期刊：
影响因子：
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通讯作者：
M. Nataloni
中科院分区：
文献类型：
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作者：
R. Mocchegiani;M. Nataloni
感染性心内膜炎（IE）是一种致命的疾病，如果不及时用抗生素治疗，无论是否与手术相关。在过去的几十年里，由于风险条件的变化，疾病的发病率并没有下降。当感染在心脏内传播时，IE的并发症可能涉及心脏结构，或者当原因通常是栓塞起源时，可能涉及心脏外的并发症;它们也可能是由于药物治疗或败血症本身造成的。大多数患者可发生多种并发症。文献报道，在接受检查的患者中，57%的患者有一种IE并发症，26%的患者有两种并发症，约14%的患者有三种或三种以上并发症。具体并发症的发生频率取决于感染病原体、治疗前疾病持续时间和治疗类型等变量。然而，通常很难评估并发症的真实发生率，因为文献中已发表的评论通常基于回顾性图表评论并且使用不同的诊断标准。关于手术适应症或时机的决定应个体化，并基于至少涉及心脏病专家和心脏外科医生的多学科方法。充血性心力衰竭（CHF）是IE最重要的并发症，对预后影响最大。环周水肿是IE的一种相对常见的并发症（手术期间或尸检时分别为42%至85%），与较高的发病率和死亡率相关。全身栓塞发生在22%至50%的病例中;栓塞可能涉及主要动脉，主要影响中枢神经系统，但也影响其他器官。脾脓肿是IE的一种罕见并发症，是由于栓子直接植入脾脏或细菌接种于温和的梗死所致。20%-40%的IE患者发生神经系统并发症，是并发症的危险子集。肌层动脉瘤是罕见的，由于感染扩散到血管壁。事实上，复杂性IE的临床特征、最佳治疗（内科或外科方法）和结局并没有很好的定义。IE病因学的变化趋势与葡萄球菌、HACEK组细菌和真菌的新感染导致培养阴性IE的频率增加。尽管进行了适当的抗菌治疗，但脓毒症或持续发热、复发性栓塞、心力衰竭或新发病理性杂音表明血流动力学损害和/或感染延伸至瓣叶或人工瓣环之外。随着手术需求的增加，疾病的进程将因此变得更糟。发生乳腺癌的患者比未发生乳腺癌的患者更有可能接受手术（84-91% vs 36%），并且他们的住院死亡率也更高（19% vs 11%）。及时发现并发症通常可以早期手术治疗，这是改善结果的最佳方法。分子方法技术的引入提高了鉴定IE致病因子的能力，主要是在培养阴性的心内膜炎病例中。超声心动图，主要来自经食管（TEE）方法，显著改善了IE的评价，允许检测疾病的特定体征，如赘生物、扩张、瓣膜关闭不全、人工瓣膜裂开、瘘。在我们的第3家转诊医院（Lancisi Heart Hospital，安科纳，意大利），我们对15例与IE相关的环周并发症患者进行了随访（平均8.26年）。长期随访显示死亡率低，再介入发生率高，存活者的纽约心脏协会（NYHA）分级改善，超声心动图检查时病变无变化，表明环周并发症对随访时患者的总生存率无显著影响。
Infective endocarditis (IE) is a lethal disease if not promptly treated with antibiotics, either in association with surgery or not. The incidence of disease has not decreased over the last decades due to the change of risk conditions. Complications of IE may involve cardiac structures when the infection spreads within the heart, or extra cardiac ones when the cause is usually from embolic origin; they may also be due to medical treatment or to the septic condition itself. A variety of complications may occur in most of patients. The literature reports one complication of IE in 57%, two in 26% and three or more in about 14% of patients examined. The frequency of specific complications depends on variables as the infecting pathogen, duration of disease before therapy and type of treatment. However it is often difficult to assess the true incidence of complications because the published reviews in literature are frequently based on retrospective chart reviews and different diagnostic criteria are used. The decision over either indication or timing of surgery should be individualized and based on a multidisciplinary approach involving at least cardiologists and cardiac surgeons. Congestive heart failure (CHF) is the most important complication of IE, which has the greatest impact on prognosis. Periannular abscesses are a relatively common complication of IE (42% to 85% of cases during surgery or at autopsy respectively), associated with a higher morbidity and mortality. Systemic embolization occurs in 22% to 50% of cases; emboli may involve major arteries, mostly affecting the central nervous system, but also other organs. Splenic abscess is a rare complication of IE, due to direct seeding of spleen by an embolus or bacterial seeding of a bland infarction. Neurological complications develop in 20% to 40% of patients with IE and represent a dangerous subset of complications. Mycotic aneurysms are rare, resulting from diffusion of infection to the vessel wall. Actually the clinical profile, the best treatment (medical or surgical approach) and outcome of complicated IE are not well defined. Changing trends in aetiology of IE with emerging infections from Staphylococci, bacteria of the HACEK group and Fungi have resulted in an increased frequency of culture negative IE. Sepsis or persistent fever despite appropriate antimicrobial therapy, recurrent emboli, heart failure or new pathologic murmurs suggest haemodynamic impairment and/or infection extending beyond the valve leaflet or prosthetic valvular annulus. The course of the disease will consequently get worse with an increasing need of surgery. Patients who develop abscesses are more likely to undergo surgery than those who do not (84-91% vs 36%), and also their in-hospital mortality rate is higher (19% vs 11%). A prompt detection of complications often allows an earlier surgical treatment which represents the best way to improve the outcome. The introduction of molecular methods techniques has increased the ability to identify the causal agents of IE, mostly in cases of culture negative endocarditis. Echocardiography, mainly from transesophageal (TEE) approach, has significantly improved the evaluation of IE allowing to detect the specific signs of the disease as vegetations, abscesses, valve insufficiency, prosthetic valve dehiscence, fistulas. In our 3rd referral Hospital (Lancisi Heart Hospital, Ancona, Italy) we performed a follow-up (mean 8.26 years) of 15 patients with periannular complications associated with IE. The long term follow-up showed low mortality rate, high incidence of reintervention, improved New York Heart Association (NYHA) class in survivors and no changes of the lesions at the echocardiographic examination, suggesting that periannular complications have not significantly influenced the overall survival in our patients at the follow-up.