本文選題：心臟植入裝置 + 感染�。� 參考：《浙江大學(xué)》2016年博士論文

【摘要】：目 的探討心臟植入裝置感染的危險因素及處理策略。方 法回顧性分析1995年1月至2016年2月在浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院心血管內(nèi)科住院治療的心臟植入裝置感染患者60例。收集患者的基本臨床資料、處理策略及隨訪資料,對患者合并疾病、手術(shù)次數(shù)、囊袋血腫等危險因素進(jìn)行總結(jié)分析,探討心臟植入裝置感染的危險因素,及心臟植入裝置感染后不同處理策略的臨床預(yù)后。結(jié)果60例患者,女性25例(41.7%),平均年齡66.3±13.4歲；20例(33.3%)病原菌培養(yǎng)陽性,40%為金黃色葡萄球菌。感染發(fā)生在CIED植入/更換術(shù)后14天到96個月(中位：18個月),其中早期感染(1月)6例(10%)、中期感染(1-12月)23例(38.3%)、延遲感染(12～24月)10例(16.7%)、遠(yuǎn)期感染(24月)21例(35%)；早期感染患者中,女性(p=0.037)、術(shù)后曾發(fā)生囊袋血腫的患者(p=0.037) CIED感染的發(fā)生率顯著增加；延遲感染患者中,合并疾病中伴有糖尿病(p=0.020)、冠狀動脈粥樣硬化性心臟病(p=0.007)、心肌病(p=0.020)、心功能不全(p=0.038),及曾植入復(fù)雜類型的CIED(包括ICD、CRT-P/D)(p=0.021)的患者CIED感染的發(fā)生率顯著增加。其中CRT-P/D感染患者5例,感染發(fā)生率為1.2%；CRT植入術(shù)后的感染風(fēng)險與高齡(p=0.044),及合并腦梗死(p=0.042)、痛風(fēng)(p0.001)、甲狀腺功能減退(p0.001)、腫瘤(p0.001)顯著相關(guān)。60例患者中,表現(xiàn)為單純囊袋感染52例(86.7%),全身感染8例(13.3%)。合并糖尿病(p=0.047)、低蛋白血癥(p=0.047)的患者,發(fā)生單純囊袋感染風(fēng)險增加；合并心肌病(p=0.007)、心功能不全(p=0.031)的患者全身感染的發(fā)生率顯著增加。所有患者入院后行清創(chuàng)引流13例(22%),電極離斷12例(20%),導(dǎo)線拔除35例(58%)；不同感染程度患者的處理策略選擇的差異均無統(tǒng)計(jì)意義。患者入院后抗生素平均應(yīng)用14.9±8.0天；全身感染組抗生素平均使用天數(shù)顯著多于單純囊袋感染組[(19.7±10.2) vs (13.0±6.5), p=0.048]。 CIED感染處理后隨訪1-90個月(中位：48個月)。其中15例感染復(fù)發(fā),復(fù)發(fā)率為25.0%,發(fā)生于抗感染治療后1-27個月(中位：5個月)；導(dǎo)線拔除組的感染復(fù)發(fā)率顯著降低(清創(chuàng)引流vs導(dǎo)線拔除,46.2%vs 5.7%,p=0.013；電極離斷vs導(dǎo)線拔除,53.8%vs 5.7%,p0.001)。根據(jù)導(dǎo)線拔除方式,分為經(jīng)靜脈組(38例)和開胸組(4例)。開胸組電極導(dǎo)線植入時間顯著長于經(jīng)靜脈組[(105.7±48.2)vs(49.0±44.0),p=0.042]；住院天數(shù)顯著長于經(jīng)靜脈組[(14.9±4.6)vs(24.3±8.1),p=0.005]。兩組患者均未出現(xiàn)嚴(yán)重并發(fā)癥,手術(shù)成功率及復(fù)發(fā)率均無顯著差異。結(jié)論本中心CIED感染病原菌以金黃色葡萄球菌為主。女性,復(fù)雜類型CIED,術(shù)后囊袋血腫及伴有冠狀動脈粥樣硬化性心臟病、糖尿病、心肌病、心功能不全均可影響CIED感染患者的感染時期；高齡,合并腦梗死、痛風(fēng)、甲狀腺功能減退、腫瘤是CRT植入患者感染的高危因素；合并糖尿病、低蛋白血癥是發(fā)生單純囊袋感染的危險因素,合并心肌病、心功能不全是發(fā)生全身血行感染的危險因素。拔除導(dǎo)線,將CIED完全移除是感染患者的最佳處理策略。經(jīng)靜脈途徑可有效拔除電極導(dǎo)線,減少患者住院天數(shù)。
[Abstract]:Objective to investigate the risk factors and treatment strategies for the infection of the heart implantation device. Methods a retrospective analysis was made of 60 cases of heart implant infection in the Second Affiliated Hospital of Zhejiang University from January 1995 to February 2016. The basic clinical data, treatment strategies and follow-up data were collected, and the patients were combined with the patients. The risk factors such as disease, operation times, bag hematoma and other risk factors were summarized and analyzed. The risk factors of infection in the heart implantation device were discussed, and the clinical prognosis of different treatment strategies after the infection of the heart implantation device. The results were 60 cases, 25 women (41.7%), the average age was 66.3 + 13.4 years, 20 cases (33.3%) were positive for pathogenic bacteria and 40% were golden yellow grapes. The infection occurred from 14 days to 96 months after CIED implantation / replacement (median: 18 months), of which 6 cases (10%) were early infection (10%), 23 cases (38.3%), 10 cases (16.7%) of delayed infection (12~24 months), 21 cases (24) (24) in delayed infection (12~24 months), and early infection patients (p=0.037) and patients who had sack hematoma after operation (p=0.03 7) the incidence of CIED infection was significantly increased; in patients with delayed infection, the incidence of CIED infection was significantly increased in patients with complicated diseases, including diabetes (p=0.020), coronary atherosclerotic heart disease (p=0.007), cardiomyopathy (p=0.020), cardiac insufficiency (p=0.038), and patients who had implanted complex types of CIED (including ICD, CRT-P/D) (p=0.021). Among the 5 cases of CRT-P/D infection, the incidence of infection was 1.2%; the risk of infection after CRT implantation was associated with the age (p=0.044), the combined cerebral infarction (p=0.042), the gout (p0.001), the hypothyroidism (p0.001), and the tumor (p0.001) significantly related to the.60 cases, 52 cases (86.7%), 8 cases of systemic infection (13.3%), and diabetes mellitus (p=0). .047), patients with hypoproteinemia (p=0.047) increased the risk of simple bag infection; the incidence of systemic infection in patients with cardiomyopathy (p=0.007) and cardiac insufficiency (p=0.031) increased significantly. All patients underwent debridement drainage in 13 cases (22%) after admission, 12 cases (20%), 35 cases (58%); The average use of antibiotics was 14.9 + 8 days after admission, and the average use of antibiotics in the whole body infection group was significantly more than that of the simple bag infection group [(19.7 + 10.2) vs (13 + 6.5), and the p=0.048]. CIED infection was followed up for 1-90 months (median: 48 months). Among them, 15 cases had recurrent infection and recurrence rate. 25%, 1-27 months after anti infection treatment (median: 5 months); the recurrence rate of infection in the wire extraction group was significantly lower (debridement and drainage vs wire extraction, 46.2%vs 5.7%, p=0.013; electrode removal vs wire extraction, 53.8%vs 5.7%, p0.001). According to the method of wire extraction, it was divided into the vein group (38 cases) and the open chest group (4 cases). The electrode guide in the open chest group. The time of line implantation was significantly longer than that of the vein group [(105.7 + 48.2) vs (49 + 44), p=0.042], and the number of days in hospital was significantly longer than that of the transvenous Group [(14.9 + 4.6) vs (24.3 + 8.1)). There were no serious complications in the group p=0.005]. two, and there was no significant difference in the success rate and recurrence rate of the operation. Conclusion the pathogen of CIED infection in this center is with Staphylococcus aureus. Women, complex type CIED, postoperatively sack hematoma and coronary atherosclerotic heart disease, diabetes, cardiomyopathy, cardiac insufficiency can affect the infection period of CIED infected patients; older age, combined cerebral infarction, gout, hypothyroidism, tumor are the high risk factors of CRT implantation in patients with infection; combined diabetes, low protein Anemia is a risk factor for a simple bag infection. Cardiomyopathy combined with cardiac insufficiency is a risk factor for systemic blood infection. Removal of traverse and complete removal of CIED are the best treatment strategies for infected patients. Through the intravenous route, the electrode leads can be removed effectively to reduce the number of patients in hospital.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R541

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