二尖瓣成形术治疗活动性感染性心内膜炎的临床分析

发布时间：2018-04-11 00:04

本文选题：感染性心内膜炎 + 二尖瓣成形术　；参考：《北京协和医学院》2015年硕士论文

【摘要】：背景：感染性心内膜炎(Infective endocarditis, IE)是一种感染累及心脏瓣膜和心内膜的严重心脏疾病,导致心功能损害、血流动力学异常。左心系统和右心系统均可受累,以左心系统最为常见,即主动脉瓣和二尖瓣常发生病损。病变主要包括血行感染和心脏结构破坏,并且可出现多种严重并发症,如急性脑血管栓塞、脑出血、感染性动脉瘤形成及破裂,可危及生命,为临床治疗决断增加困难。IE治疗难度大,存在猝死风险,死亡率较高。本文为回顾性临床观察研究,目的在于总结二尖瓣成形术(MVP)在涉及二尖瓣病变的IE患者有关的外科治疗临床经验,探讨MVP治疗IE的效果及预后和相关临床特征。方法：连续选取从2011年2月至2015年2月的4年期间于北京协和医院心外科收治的活动性期IE患者共40例,全部符合IE诊断标准,病变累及二尖瓣,并因此接受二尖瓣成形术(MVP)。患者平均年龄42.4±14.9岁(最小年龄21岁,最大年龄82岁),男性65.0%(26/40),女性35.0%(14/40)。22名患者血培养阳性,占全部病例55%。致病病原体主要为革兰阳性菌(G+细菌),并且链球菌占大多数,占37.5%(15名患者),其他病原体有布氏杆菌和分支杆菌；血培养阴性的IE 18例(45%)；所有患者均在第一时间接受抗感染治疗。自就诊至手术时间平均为11.4±12.2天。所有患者均为胸骨正中切口入路,且在全麻低温体外循环(CPB)进行手术,CPB建立方式为升主动脉和上、下腔静脉插管,升主动脉阻断,顺灌+逆灌含血停跳液保护心肌。结果：所有患者均进行二尖瓣成形术(MVP),34例使用人工法规尖瓣成形环,13例使用自体心包补片,7例使用人工腱索,1例腱索转移。人工二尖瓣成形环平均尺寸29.3±2.1mm。1名患者因感染未能有效控制、多脏器功能衰竭(MODS)于术后第5天死亡,1名患者术后2个月因金葡菌血行感染和MODS死亡。1名患者因溶血于术后第15天转行二尖瓣机械瓣置换术(MVR)。术后随访发现左室舒张末内径(LVEDD)明显减小(56.8±6.7 vs.49.7±5.7 mm),NYHA分级明显减低(2.25±1.07 vs.1.06±0.25)。2名患者因残存二尖瓣返流(MR)分别于术后第3和5个月再次手术转行二尖瓣机械瓣置换术(MVR)。总结：结果显示心功能明显改善,LVEF提升,左室内径减小。二尖瓣成形术在活动性IE中具有良好治疗效果。
[Abstract]:Background: infective endocarditis (IEE) is a serious heart disease that affects heart valve and endocardium, resulting in cardiac dysfunction and abnormal hemodynamics.The left heart system and the right heart system are both involved, and the left heart system is the most common, that is, the aortic valve and mitral valve are often damaged.The pathological changes mainly include infection of blood and destruction of heart structure, and many serious complications may occur, such as acute cerebral vascular embolism, cerebral hemorrhage, formation and rupture of infectious aneurysms, which can be life-threatening.The treatment of IE is difficult, there is a risk of sudden death, and the death rate is high.The purpose of this paper is to summarize the surgical experience of mitral valvuloplasty (MVP) in the treatment of IE patients with mitral valve disease, and to explore the effect, prognosis and clinical features of MVP in the treatment of IE.Methods: a total of 40 patients with active IE were selected from February 2011 to February 2015 in cardiac surgery department of Peking Union Hospital. All of them met the diagnostic criteria of IE and involved mitral valve, and received mitral valvuloplasty (MVPU).The average age of the patients was 42.4 卤14.9 years old (the youngest 21 years, the maximum 82 years old, male 65.0%, 26% 40%, women 35.0% 14% 40%, 22 patients), accounting for 55% of the cases.The main pathogens were Gram-positive bacteria G bacteria, and streptococcus accounted for the majority, accounting for 37.5% of the 15 patients, other pathogens were Brucella and Mycobacterium; 18 cases of IE with negative blood culture were treated with anti-infective therapy at the first time.The average time from visit to operation was 11.4 卤12.2 days.All patients were treated by median sternum incision and CPB was operated on under general anesthesia hypothermic cardiopulmonary bypass (CPB). CPB was established by intubation of ascending aorta, upper and lower vena cava, occlusion of ascending aorta, and perfusion of blood cardioplegia to protect myocardium.Results: all the patients were treated with mitral valvuloplasty and mitral valvuloplasty in 34 cases. 13 cases were treated with autologous pericardial patch, 7 cases were treated with artificial chordae tendineae and 1 case with chordae tendineae.The mean size of the artificial mitral valvuloplasty ring was 29.3 卤2.1mm.1, which could not be effectively controlled because of infection.One patient died of staphylococcus aureus blood infection 2 months after operation and one patient died of MODS hemolysis. On the 15th day after operation, mitral valve mechanical valve replacement was performed in 1 patient.Conclusion: the results showed that cardiac function significantly improved LVEF and decreased left ventricular diameter.Mitral valvuloplasty has a good therapeutic effect in active IE.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R654.2

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