Surgical Treatment Of Infective Endocarditis

Objective:In a prospective, the surgical treatment of 42 patients with infective endocarditis was reviewed and summarized.Methods:In this study, we used antibiotics in all 42 cases before surgical procedure, and one or two or more broad-spectrum antibiotic treatment were used in the cases with not clear pathogens or negative blood culture. Antibiotics were selectively used in positive blood culture cases according to the antibiotic sensitivity test. The application of antibiotics was continued to use after surgery. 40 cases underwent surgery after the infection under control, and 2 cases (1 case with the aortic valve disease, the other case with tricuspid valve disease) underwent the emergent valve replacement because infection was still out of control after actively treated with antibiotics and cardiac dysfunction progressively exacerbated. All 41 cases were operated under cardiopulmonary bypass and the remaining 1 case underwent PDA ligation through left thoracotomy because no clear vegetation could be seen in the preoperative echocardiography and the infection was under control so soon after the treatment of large doses of antibiotics that the body temperature returned to be normal level. The vegetations could be seen intraoperatively in all 41 cases introoperation, which were crisp, small or big, single or multiple, the vegetations were located around the VSD in 6 cases, on the side of the pulmonary artery of PDA in 2 cases, involving mitral valve in 13 cases, aortic valve in 26 cases and tricuspid valve in 2 cases, on the chordae tendineae and left ventricular surface in 5 cases, in the main pulmonary trunk in 1 case. The leaf of mitral valve perforated in 2 cases, and the chordae tendineae of the mitral valve ruptured in 2 cases.Surgical treatment: after removal of the vegetations completely, smear with Iodophor, then wash with the normal saline plus antibiotics. Repair the defect of the patients with the congenital heart disease complicated by IE, in which 6 cases of VSD repair surgery, 4 cases of patent ductus arteriosus ligation, 1 case of ASD repair were operated, 6 cases of aortic valve replacement (AVR) in congenital aortic valve-bicuspid valve malformations, and 1 case of mitral valvuloplasty were operated. For the cases with the rheumatic valvular disease complicated by IE, remove the vegetations and treat the valve disease at the same time after Iodophor smearing, in which 10 cases of AVR, 8 cases of mitral valve replacement (MVR), 5 cases of double mitral and aortic valve replacement surgery (DVR), and 1 case of tricuspid valve replacement (TVR) were carried out. Mechanical valves (including CarboMedics valve in 15 cases, Tilted butterfly valve in 6 cases, St.Jude Medical valve in 8 cases, and Sorin valve in 6 cases) were used in valvereplacement. In the same period, 6 cases of tricuspid valvuloplasty were used. All cases continued to be treated with antibiotics after surgery.Results:There was no intraoperative mortality in our group. There were 4 cases of deaths in the early stage after surgery, in which 2 cases appeared coma, multiple organ failure and died after surgery; 1 case with severe aortic insufficiency died on the seventh day after the occurrence of acute left heart failure; 1 case with aortic valve insufficiency complicated by IE appeared to have a fever on the seventh day after surgery, whose WBC continued to rise and the infection were still out of control despite of active antibiotic therapy, so the fever was persistent high, and were confirmed to be prosthetic valve endocarditis by echocardiography (on the 14th day), though the patient accepted antibiotic treatment, the pathogen had not yet been detected despite of frequent blood culture before and after operation, and unfortunately the patient died onset of cerebral hemorrhage. 38 cases discharged with the normal temperature, no signs of infection in other organs, the normal blood and erythrocyte sedimentation rate, the correct orthopedic confirmed by echocardiography, no residual shunt, and good prosthetic valve headstock. The discharged patients from hospital were follow-up through the out-patient or letters, and follow-up time was 1～52 months, as a result, there was no long-term mortality and recurrence, the cardiac function returned to GradeⅠ～Ⅱ.Conclusions:1,In the early diagnosis of IE, the positive rate of the blood culture was not high, but the blood culture should be repeated in patients with suspected IE and antibiotics sensitivity test. Echocardiography for the diagnosis and treatment of IE was very important, and the cases which could not be diagnosed by conventional echocardiography were to be confirmed by transesophageal echocardiography.2,At the same time the anti-infection therapy stressed, surgical treatment should be taken on a positive attitude.3,The cases of negative blood culture before surgery should continue to do the blood culture, if obtaining positive results, select the sensitive antibiotics according to drug-sensitive test. The antibiotics treatment should be used at least for more than 2 weeks. If the body temperature returned to normal level, and blood culture test was negative, another 2 weeks should be taken with the treatment of antibiotics; if negative result, select two kinds of broad-spectrum antibiotics for antibiotic treatment of 2~4 weeks.