活动期感染性心内膜炎手术时机的分析

【】　目的　探讨活动期感染性心内膜炎（infectiueendocarditis，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SPSS12.0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7d内手术，36例患者在确诊7d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　Todiscusstheoptimaltimeofcardiacoperationsinpatientswithinfectiveendocarditis(IE).　Methods　Weanalyzedtheclinicaldataof92patientswithIEdiagnosedbythemodifiedDukecriteriabetweenSeptember1999andSeptember2009.SPSS12.0wasusedtoanalyzepredictorsof6-monthmortality,includingage,sex,nosocomialoriginofinfection,comorbidconditions(diabetes,chromicobstructivepulmonarydisease,cancer),thecausativemicroorganisms,thetimingofcardiacoperation,andthecomplications.　Results　Fifty-sixpatientsunderwentoperationwithinthefirst7daysafterdiagnosisofinfectiveendocarditis,and36receivedoperationatthecompletionofantibiotictreatment7daysafterthediagnosis.Staphylococcipredominatedandweresignificantlyassociatedwithembolism,abscess,andsepticshock.Themostfrequentindicationforoperationwassevereregurgitationwithheartfailure.The6-monthmortalitywas12%.Earlyoperationshowedanincreasedmortalitycomparedwithlateoperation.Univariateanalysisshowedthatfactorsassociatedwith6-monthmortalityincludedstaphylococciinfectionandsepticshock.Multivariateanalysisrevealedthatsepticshockwasapredictorof6-monthmortality.Despiteearlyoperationforpatientswithsepticshock,67%ofthemdied.Nodeathoccurredtopatientswithsevereregurgitationbutwithoutheartfailureafterundergoing(earlyorlate)operations.　Conclusions　Theprognosisforsurgicallytreatedpatientsisdeterminedbytheoccurrenceofsepticshock.Theoutcomeinpatientsundergoinglateoperationsisfavorablecomparedwithpatientsundergoingearlyoperations.Thisdifferenceisprobablynotduetothetimingofthesurgicalinterventionbuttotheseverityofinfectiveendocarditis.Inpatientswithsevereregurgitationwithoutheartfailure,earlyoperationmayofferbenefitsinshorteningthelengthofhospitalizationandpreventingdevelopmentofheartfailure.