本文選題：感染性心內(nèi)膜炎 + 二尖瓣成形術(shù)　； 參考：《北京協(xié)和醫(yī)學(xué)院》2015年碩士論文

【摘要】：背景：感染性心內(nèi)膜炎(Infective endocarditis, IE)是一種感染累及心臟瓣膜和心內(nèi)膜的嚴(yán)重心臟疾病,導(dǎo)致心功能損害、血流動(dòng)力學(xué)異常。左心系統(tǒng)和右心系統(tǒng)均可受累,以左心系統(tǒng)最為常見,即主動(dòng)脈瓣和二尖瓣常發(fā)生病損。病變主要包括血行感染和心臟結(jié)構(gòu)破壞,并且可出現(xiàn)多種嚴(yán)重并發(fā)癥,如急性腦血管栓塞、腦出血、感染性動(dòng)脈瘤形成及破裂,可危及生命,為臨床治療決斷增加困難。IE治療難度大,存在猝死風(fēng)險(xiǎn),死亡率較高。本文為回顧性臨床觀察研究,目的在于總結(jié)二尖瓣成形術(shù)(MVP)在涉及二尖瓣病變的IE患者有關(guān)的外科治療臨床經(jīng)驗(yàn),探討MVP治療IE的效果及預(yù)后和相關(guān)臨床特征。方法：連續(xù)選取從2011年2月至2015年2月的4年期間于北京協(xié)和醫(yī)院心外科收治的活動(dòng)性期IE患者共40例,全部符合IE診斷標(biāo)準(zhǔn),病變累及二尖瓣,并因此接受二尖瓣成形術(shù)(MVP)。患者平均年齡42.4±14.9歲(最小年齡21歲,最大年齡82歲),男性65.0%(26/40),女性35.0%(14/40)。22名患者血培養(yǎng)陽性,占全部病例55%。致病病原體主要為革蘭陽性菌(G+細(xì)菌),并且鏈球菌占大多數(shù),占37.5%(15名患者),其他病原體有布氏桿菌和分支桿菌；血培養(yǎng)陰性的IE 18例(45%)；所有患者均在第一時(shí)間接受抗感染治療。自就診至手術(shù)時(shí)間平均為11.4±12.2天。所有患者均為胸骨正中切口入路,且在全麻低溫體外循環(huán)(CPB)進(jìn)行手術(shù),CPB建立方式為升主動(dòng)脈和上、下腔靜脈插管,升主動(dòng)脈阻斷,順灌+逆灌含血停跳液保護(hù)心肌。結(jié)果：所有患者均進(jìn)行二尖瓣成形術(shù)(MVP),34例使用人工法規(guī)尖瓣成形環(huán),13例使用自體心包補(bǔ)片,7例使用人工腱索,1例腱索轉(zhuǎn)移。人工二尖瓣成形環(huán)平均尺寸29.3±2.1mm。1名患者因感染未能有效控制、多臟器功能衰竭(MODS)于術(shù)后第5天死亡,1名患者術(shù)后2個(gè)月因金葡菌血行感染和MODS死亡。1名患者因溶血于術(shù)后第15天轉(zhuǎn)行二尖瓣機(jī)械瓣置換術(shù)(MVR)。術(shù)后隨訪發(fā)現(xiàn)左室舒張末內(nèi)徑(LVEDD)明顯減小(56.8±6.7 vs.49.7±5.7 mm),NYHA分級(jí)明顯減低(2.25±1.07 vs.1.06±0.25)。2名患者因殘存二尖瓣返流(MR)分別于術(shù)后第3和5個(gè)月再次手術(shù)轉(zhuǎn)行二尖瓣機(jī)械瓣置換術(shù)(MVR)�？偨Y(jié)：結(jié)果顯示心功能明顯改善,LVEF提升,左室內(nèi)徑減小。二尖瓣成形術(shù)在活動(dòng)性IE中具有良好治療效果。
[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 鹵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 鹵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 鹵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.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R654.2

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