二尖瓣置换术后感染性心内膜炎的治疗  

Treatment for prosthetic valve endocarditis after mitral valve replacement therapy

作　　者：郑家豪[1] 薛松[1] 徐根兴[1] 黄日太[1] 殷荣[1] 刘冀东[1] 朱洪生[1] 

机构地区：[1]上海交通大学医学院附属仁济医院心胸外科,200127

出　　处：《中国综合临床》2012年第2期201-204,共4页Clinical Medicine of China

摘　　要：目的回顾二尖瓣人工瓣膜置换术（MVR）后感染性心内膜炎（PVE）患者的治疗经验。方法1979年9月至2010年12月，我科共收治依据修正的Duke大学诊断标准确诊的MVR术后的PVE患者16例，男10例，女6例；年龄19～55岁，中位年龄28岁，PVE的发生率为0．97％（16／1657）。术前血培养阳性5例；单纯内科保守治疗10例；内、外科联合治疗6例，其中1例因难以纠治的心力衰竭急诊手术，另5例经抗生素治疗，全身情况改善后择期手术；手术拆除感染的人工瓣膜后彻底清除周围的感染组织和赘生物，用稀释的氟氯溴碘溶液及大量生理盐水反复冲洗，重新置换新的人工瓣膜，同期行三尖瓣成形（TVR）3例。结果采用单纯内科方法治愈2例，死亡8例，其中死于中毒性休克、心力衰竭4例，死于脑部并发症（包括脑栓塞、脑出血）、多器官功能衰竭4例；内、外科联合方法治愈6例。术后随访8例，随访时间1．7～16年，平均5．1年。随访期间除1例患者于术后8年由于二尖瓣人工机械瓣瓣周漏和重度三尖瓣关闭不全而行瓣周漏修补加三尖瓣置换外，其余7例随访患者无感染复发。结论内、外科联合治疗MVR术后PVE患者效果优于单纯内科治疗。及时诊断、足量足时敏感抗生素的应用、把握手术时机、感染组织的彻底清除、术中良好的心肌保护是预后的关键。Objective To review the experience of treatment for prosthetic valve endocarditis （PVE） after mitral valve replacement （MVR） in 16 eases. Methods From September 1979 to December 2010, 16 patients were diagnosed as PVE after MVR by modified Duke University diagnostic criteria. There were 10 males and 6 females. Their ages ranged from 19 to 55 years old （mean 28 years old）. The incidence of PVE was 0. 97% （16/1657）after MVR. Blood culture positive was in 5 cases. Medical treatment alone was performed in 10 patients who were treated by using Penicillin or Vaneomycin with other broad-spectrum antibiotics, using Fluconazole and Amphoteriein if necessary. Combined medical and surgical management were performed in 6 cases. One emergency ease was operated because of obstinate heart failure. Five eases underwent operation after adequate antibiotics treatment and general condition improvement. The infective tissue and vegetation were aggressively debrided after the infective prosthetic valve removed. Before the new valve was replaced paravalvular tissue must be flushed with diluted iodine solution and large quantities of normal saline. Tricuspid valve repair （TVR）was performed during the same period in 3 cases. Results Hospital death occurred in 8 patients and only 2 patients were recovery in group with medical treatment only. The main reasons of death were infective shock and cardiac failure in 4 patients, cerebral complications （embolism or bleeding）and multiple organs failure in 4 cases. While 6 patients cured after combined medical and surgical management. Follow-up had been carried out in 8 cases for 1.7 to 15 years （mean 5.1 years）. Eight years later one patient was re-operated because of severe tricuspid regurgitation and paravalvular leak. There was no PVE recurrence in others. Conclusion Combined medical and surgical management for PVE get a better result than medical treatment alone. Good prognosis lies in timely diagnosis, adequate antibiotics, aggressive debridement of infective tiss

关 键 词：二尖瓣置换术 人工瓣膜感染性心内膜炎 内 外科联合治疗 

分 类 号：R654.2[医药卫生—外科学]