感染性心内膜炎30例临床及预后分析

为探讨感染性心内膜炎（IE）的临床特及预后因素，对15年来的收治的30例IE患儿的所有资料进行回顾性调查，结果30例IE患儿治愈9例，死亡5例；持续发热为其主要表现，血培养阳性18例（60．0％），其中金葡菌9例（50．0％）；超声检查发现赘生物21例，有赘生物及基础心脏病组死亡率为23．8％和25．0％，无赘生物和无基础心脏病组无死亡；栓塞组死亡21．4％，无栓塞组为12．5％；血培养阳性组死亡22．2％，阴性组为8．3％。提示IE的显著症状是持续发热，金葡菌感染占首位，预后与赘生物、栓塞、基础心脏病存在和血培养阳性有关。     

感染性心内膜炎28例

目的 总结小儿感染性心内膜炎(IE)临床表现特点及治疗经验,以利于早期诊断和治疗。方法对1980~2002年住院28例IE患儿的临床表现、诊断、治疗、及预后进行回顾性分析。结果 临床表现以发热、心脏杂音多变、心力衰竭、贫血、白细胞增高和血沉加快为主.血培养阳性9例(32.1％)。发现心内赘生物22例(78.6％)。6例行外科手术治疗,手术后均治愈。治愈20例(71.4％),自动出院2例,死亡6例。结论 先天性心脏病(CHD)患儿出现不明原因长时间发热,无基础心脏病感染发热患儿发现心脏杂音,均应及时做连续规范血培养及超声心动图检查,以利于早期诊断和治疗。IE患儿经抗生素治疗后心内赘生物不消失或出现顽固性、进行性心衰时应进行外科手术治疗,及时采用手术治疗对改善这类患儿预后有重要意义。     

Duck标准对感染性心内膜炎的诊断和治疗价值

目的探讨修改后Duck标准对儿童感染性心内膜炎(IE)的诊断和治疗价值。方法将22年来我院收治的73例先天性心脏病(先心病)并IE患儿,按照Duck标准作回顾性分析。结果确诊IE 37例(51%),其中16例(43%)外科手术时行病理活检形态学诊断,8例(22%)符合2项主要临床诊断标准,13例(35%)符合1项主要及≥3项次要指标。可能为IE 36例(49%)。抗生素治愈45例(62%);药物不能控制感染,发现有赘生物,手术清除及心脏畸形矫治16例(21%)。死亡12例(17%),其中1例术后死亡。结论IE仍是先心病严重的并发症,Duck标准临床诊断应用相对过严,特异性较高;但当赘生物形成尚未达到一定程度时,修改后Duck标准不能早期诊断。外科手术疗效满意,内外科联合治疗能有效降低死亡率。     

先天性心脏病继发感染性心内膜炎患儿的外科治疗

目的总结小儿先天性心脏病(先心病)继发感染性心内膜炎(IE)外科治疗的临床经验。方法本院2002年1月-2011年4月收治先心病并IE患儿15例。男7例,女8例;年龄3～12岁;体质量10～27 kg。术前血培养均阳性,其中链球菌7例,葡萄球菌6例,其他细菌2例。超声心动图示心内膜赘生物15例,其中二尖瓣或(和)三尖瓣赘生物13例,补片上赘生物2例,并瓣膜穿孔3例,手术彻底清除感染病灶,重建受损心内结构,同时矫治先心病畸形。手术方式:VSD修补4例,ASD修补2例,ASD/VSD修补+三尖瓣成形术5例,ASD修补+二尖瓣置换术+三尖瓣成形术2例,涤纶补片摘除+VSD修补1例,右心室流出道重建术1例。体外循环(CPB)采用中低温(26～30℃),中高流量80～120 mL.kg-1.min-1灌注。心肌保护方式为使用St.ThomasⅡ冷晶体或4℃冷血液心脏停搏液(血晶体=41)顺行灌注。结果 CPB总时间85～180 min,主动脉阻断时间40～120 min,患儿均顺利脱离CPB,无CPB相关并发症,术后感染治愈。术后重症监护室监护时间1～6 d,住院时间40～60 d。本组2例术中探查发现并右上肺肺段栓塞;3例伤口感染;1例术后出现急性肾功能不全。随访3个月～9 a,1例术后2 a死亡,死亡原因为心力衰竭;余14例患儿无IE复发。结论积极手术干预的理念、准确的手术方式、个体化CPB对患儿恢复至关重要。     

先天性心脏病合并感染性心内膜炎42 例患儿超声分析

目的评价超声心动图在诊断先天性心脏病(CHD)并发感染性心内膜炎(IE)中的价值。方法回顾分析2009年1月-2018年7月住院确诊CHD并发IE患儿的临床资料。结果共42例CHD并发IE患儿,男20例、女22例;中位年龄7岁1个月,其中学龄期儿童17例(40.5%),婴幼儿15例(35.7%)。术前27例,其中左向右高速分流型19例(70.4%);术后15例。主要CHD类型为室间隔缺损(VSD)19例(45.2%)和复杂型CHD 10例(23.8%)。临床表现为发热37例(88.1%),血培养阳性18例(43.9%)。超声提示赘生物者共24例,术前16例(38.1%),术后8例(19.0%),另术前左心内膜增厚伴回声增强1例,总阳性率59.5%。共发现赘生物38处,最常见位于瓣膜,22处。术前组11例行手术治疗,证实赘生物10例(另1例术前检查赘生物持续缩小),术中发现瓣膜相关损伤5例(45.5%);余转院继续治疗3例,未愈2例。术后组在随访中超声发现赘生物缩小或消失5例,转院治疗2例,未愈1例。超声发现合并心包积液3例,外周血管栓塞1例,均为术前。临床赘生物患儿有效治疗16例,无赘生物患儿有效治疗15例,总有效治疗率73.8%。结论超声对CHD并发IE患儿的诊断、评估病情发展及预后方面可提供有效的依据。     

儿童感染性心内膜炎临床特点变化及病原学变迁

目的分析儿童感染性心内膜炎临床特点变化及病原菌的变迁，为临床诊治提供进一步指导。方法回顾分析10年中我院73例14岁以下儿童感染性心内膜炎患儿外科手术的临床资料。并将1995年1月-1999年12月的32例（Ⅰ组）与2000年1月-2004年12月的41例（Ⅱ组）做统计学分析对比，比较两组病例临床特点的变化及病原菌的变迁。结果73例患儿占同期同年龄组住院患儿总数的7．3％（73／998），Ⅱ组的比例（41／671，6．1％）低于Ⅰ组（32／327，9．8％，P〈0．05）。66例有基础心脏病，其中室间隔缺损（VSD）47例，动脉导管未闭（PDA）15例，其他4例。心脏赘生物的检出率，Ⅱ组的比例（27／41，65．9％）高于Ⅰ组（15／32，46．9％，P〈0．01）。59例血细菌培养阳性，14例血细菌培养阴性。总的细菌培养阳性率为73．9％（54／73），Ⅰ组为96．88％（31／32），Ⅱ组为68．29％（28／41）。心脏赘生物的检出率增高，由Ⅰ组的46．9％（15／32）增高为Ⅱ组为65．9％（27／41）。儿童IE的病原菌菌谱发生明显变化，革兰阳性球菌的阳性检出率明显减少，而革兰阴性杆菌的检出率明显增加。结论外科治疗的儿童感染性心内膜炎临床特点发生一定变化，血培养的阳性率降低，而心脏赘生物的检出率增高。儿童IE的病原菌菌谱中革兰阴性杆菌所占比例有明显的增高。     

儿童感染性心内膜炎33例临床特点及疗效分析

目的 探讨儿童感染性心内膜炎的临床特点及影响疗效的因素。方法 回顾性研究2013年11月至2015年11月上海儿童医学中心心内科诊断并治疗的33例感染性心内膜炎患儿的临床资料,分析其病原学特点、心脏基础疾病、赘生物分布特点、治疗方案及预后情况。结果 感染性心内膜炎病原菌的检出率为75.76%。具有先天性心脏基础疾病的比例为93.94%。赘生物主要位于反流的瓣膜,占63.64%,其次为植入的人工材料、缺损处分流及血流冲击处等。手术结合足疗程的抗感染治疗效果较好。结论 感染性心内膜炎的血培养阳性率高,且多发生于具有心脏基础疾病的患儿。早期彻底的手术治疗联合全程抗感染治疗是治疗感染性心内膜炎的关键。     

V3通用引物联合多重PCR检测感染性心内膜炎病原菌

目的 了解2007年至2010年21例在上海儿童医学中心接受手术治疗的急性感染性心内膜炎(infective endocarditis,IE)患儿的病原菌分布.方法 21例IE患儿均行血培养、赘生物培养及赘生物PCR检测(以16SrRNA基因的保守区序列V3为靶基因);对葡萄球菌进行多重PCR扩增检测耐甲氧西林葡萄球菌.结果 21例IE患儿赘生物PCR阳性检出率95.2％,血培养阳性检出率57.1％,赘生物阳性检出率9.5％,3种方法阳性检出率的差别有统计学意义(P ＜0.0001).其中1例心内膜赘生物的PCR结果与血培养结果不一致,赘生物PCR结果为放射菌,血培养结果为溶血巴斯德菌,利用血培养得到的菌落进行PCR检测,与赘生物PCR的结果一致,均为伴放线放线杆菌;其余11例心内膜标本的PCR结果与血培养结果一致.多重PCR技术检测mecA基因能快速、敏感、准确地检测耐甲氧西林葡萄球菌,与femA基因联合检测能有效检测耐甲氧西林金黄色葡萄球菌,及时提示临床使用糖肽类抗生素.21例患儿均痊愈出院,术后随访无感染复发.结论 V3通用引物联合多重PCR法可提高IE患儿赘生物病原菌检出率,且受抗菌药物的影响小,适用于符合手术指征且血培养阴性或鉴别困难的病原学诊断,有利于手术后抗菌药物的选用及提高IE的最终治愈率.     

Duke标准在小儿感染性心内膜炎诊断中的价值

目的：探讨Duke标准对小儿感染性收内膜炎诊断的价值。方法：应用Duke标准对50例临床诊断为感染 心内膜炎并经超声心动图检查的患儿及其中经手术证实为IE的患儿进行分组分析。结果：连续2次或2次以上血培养阳性并为相同致病菌的有15例（30％）,1次血培养阳性10例（205）,39例（78％）超声心动图检出赘生物,其中26例的螯生物呈摆动状态。有1例伴瓣膜穿孔,1例伴室间隔缺损补片脱落,按Duke标准,50例患儿中21例（42％）被确诊为IE。其中12例符合2项主要指标。9例符合1项主要和≥3项次要指标。1例被排除IE。在13例经手术证实的IE必中按Duke标准诊IE5例（385）,8例为可能IE,其中6例符合1项主要和2项次要指标,2例符合1项主要和1项次要指标。手术证实为IE的13例患儿中,10例血培养阴性,2例赘生物不摆动。结论应用超声心动图检出赘生物对IE诊断有重要意义,在儿科病例中螯生物的确定不必限于摆动的团块。曾用抗生素治疗,有典型心内膜受累的超心动图表现,另具备Duke标准中2项临床次要指标的可确诊为IE,这样将会进一步提高Duke标准诊断IE的敏感性。     

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目的探讨儿童感染性心内膜炎(IE)的临床特点、治疗方法及转归。方法回顾分析中南大学湘雅二医院儿科1980—2004年确诊的174例IE患儿的临床特点。174例患儿中男94例,女80例,年龄3个月至14岁,病程3d至4个月。结果(1)99例IE发生在先天性心脏病的基础上,35例发生在风湿性心脏病的基础上,35例发生在无器质性心脏病基础上,4例于先天性心脏病手术后发生,1例发生在肥厚性心肌病的小儿。(2)临床主要表现:发热(150例,86·2%)、肝大(74例,42·5%)、脾大(55例,31·6%)、贫血(65例,37·4%)、血沉增快(68例,39·1%)、多发性脏器栓塞(34例,17·8%)。细菌培养76例(76/174)阳性,阳性率43·7%,其中55例为葡萄球菌。(3)受累瓣膜以二尖瓣赘生物最多见,占48·3%。(4)并发症以顽固性心衰为主(25·2%),其次为神经系统并发症(13·2%),瓣膜腱索断裂最少见(0·57%)。(5)由于IE临床表现很不典型,病例早期被误诊为流感、肺结核、急性风湿热、肾小球肾炎等10余种疾病。(6)治愈率为60·9%,其中单用抗生素治疗治愈76例(71·6%),抗感染治疗联合外科手术治愈30例(28·3%)。死亡28例(16·1%),脑栓塞及顽固性心衰是IE最常见的死亡原因。结论发生IE的基础心脏病中,先天性心脏病跃居首位,风湿性心脏病逐渐减少。血培养、超声心动图检查有助于IE的诊断。对于IE最重要的治疗措施是应用抗生素,若经内科治疗效果不满意应尽早考虑外科治疗。     

Spectrum of infective endocarditis during infancy and childhood: 20-Year review

Summary The medical records of the 29 patients under 18 years of age with infective endocarditis (IE) seen over a 20-year period by our department were reviewed to provide an overview of the spectrum of IE during infancy and childhood. None of the 29 patients had had previous cardiovascular surgery. The mean age at onset of IE was 7 years 2 months; 3 patients (10%) were under 2 years of age at onset. One patient during the early years died following 4 months of treatment with various antibiotics. Three patients underwent urgent surgery, and 17 patients with healed IE had elective surgery. All of the 20 patients who were operated on survived. The remaining 8 were followed with medical treatment alone. Positive blood cultures were obtained from 24 (83%) patients, and streptococci were still commonly found (38%). Ventricular septal defect (VSD) accounted for 66% of underlying heart diseases and rheumatic heart diseases for 14%. Vegetations were detected in 12 (67%) of 18 patients observed by echocardiography. Among these 12 patients, 1 with VSD underwent urgent tricuspid valve replacement and VSD closure because of worsening congestive heart failure due to progressive tricuspid regurgitation. Echocardiography identifies patients at high risk with IE, though the presence of a vegetation on echocardiography does not necessarily of itself dictate surgical intervention.     

Infective endocarditis in children. Apropos of 13 cases

From 1978 through 1987, thirteen pediatric patients aged 14/12 years to 16/12 years were hospitalized for infective endocarditis (IE). Ten cases presented as acute septicemia with modification or development of a murmur and/or heart failure. Three patients had subacute endocarditis. Prior to the endocarditis, ten patients had recognized heart disease, whereas three had no known cardiac abnormality. The organism was recovered in seven cases, from blood cultures in six cases (3 Staphylococcus aureus, 1 group D streptococcus, 1 Staphylococcus albus, and 1 Salmonella typhi) and from a prosthesis in one case (Corynebacterium). Echocardiography confirmed the diagnosis in every patient except the one that had a prosthesis. Although all the patients received parenteral antimicrobial therapy, selected according to bacteriologic data when available, complications developed in every case, including heart failure in nine patients. Three children died, eight underwent valve replacement or repair once the infection was under control, and two have residual valvular disease. This study confirms that, in pediatric patients, the prognosis of IE remains severe despite advances in antimicrobial therapy and the contribution of echocardiography.     

Infective endocarditis in children

Between January 1977 and December 1982, 34 patients below the age of 20 years (age range 1.9–20 yr, mean 12.3 years) were treated for 38 episodes of infective endocarditis (IE). Twenty three patients (68%) had rheumatic heart disease (RHD), while 11 had congenital heart disease (CHD). Echocardiography was diagnostic of IE in 10 of 12 patients (83%) in whom it was performed. Blood culture was positive in only 15 instances (40%), staphylococcus being the most common organism isolated. Twenty eight (74%) episodes of IE resulted in a cure by medical treatment. Ten patients (26%) died during the medical treatment 9(90%) because of relentless congestive heart failure and 1(10%) due to cerebral embolism. Infective endocarditis in children is an important therapeutic problem. Culture negative endocarditis is frequent in our setting.     

Complications and outcome in left-sided endocarditis in children

We retrospectively assessed the clinical course and outcome of left-sided endocarditis in pediatric patients to find out the prognostic significance of the presence and size of echocardiographically detected vegetations. Among the children admitted to our institution with endocarditis between January 1987 and October 1999, 16 patients (mean age 9.03 +/- 4.95 years) who met the Duke criteria for the diagnosis of infective endocarditis (IE) were included in this study. Rheumatic valvular disease was the most frequent underlying heart disease (10 patients: 62.5%). Five patients were operated at a mean of 13.9 months before endocarditis, and all had residual defects. Vegetation was detected in 11 cases (69%). Ten patients had major complications (within 2 weeks in 6 patients). Three patients developed congestive heart failure (CHF), six had intracranial and one had lower extremity emboli. Among them four were operated because of complications (CHF: 3 cases, intracranial emboli: 1 case). All the operated cases are doing well. The association between intracranial embolic events and echocardiographically detected vegetations was determined by calculating specificity (40%), sensitivity (100%), positive predictive value (50%), and negative predictive value (100%). No intracranial embolism occurred in patients without vegetations. All vegetations were < or = 6 mm in patients with systemic embolism. There were four deaths, three of which were because of intracranial embolism. This study suggests that intracranial emboli have a major risk of mortality in left-sided endocarditis. The larger size of the vegetation is not a predictor of complications; furthermore, the absence of vegetations predicts that the patient is safe from embolic events. Therefore all patients with left-sided IE should be considered for earlier surgical intervention.     

Paediatric infective endocarditis: 19-year experience at a tertiary care hospital in a developing country

A retrospective study was undertaken to study children who presented with infective endocarditis (IE) to a university teaching hospital in Beirut, Lebanon, between January 1977 and May 1995. Of 41 patients with IE (24F, 17M), 28 (68%) were diagnosed between 1977 and 1985. Patients' ages ranged from 3 to 18 y (mean age 11.3+/-2.8 y), and 13 patients were <10 y of age. Clinical presentations included: fever (in 88%), heart failure (in 39%), neurologic findings (in 20%) and embolic phenomena (in 22%). Nineteen patients (46%) had underlying congenital heart disease (CHD) with tetralogy of Fallot and pulmonary stenosis being the most common. Sixteen patients (39%) had underlying rheumatic heart disease (RHD). A total of 5 children (12%) with normal cardiac anatomy had IE. One had underlying acquired viral myocarditis with mitral insufficiency. Echocardiography showed vegetations in 60%. Blood cultures were positive in 31 patients (76%). IE occurred in three patients following cardiac surgery. In one patient it occurred within 2 mo of surgery and in the other two it occurred within 6 mo. Streptococcus viridans and Staphylococcus aureus were the two most commonly isolated bacteria. Overall mortality rate was 29% (not statistically significant between patients presenting between 1977-1985 and 1986-1995; p = 0.17). There was no statistically significant difference in mortality among the groups (five in the group with CHD, six with RHD and one with structurally normal heart). This study demonstrates that RHD is an important underlying cause of IE in children in our community. This finding is similar to those in other developing countries and different from those in developed countries. Distribution of pathogens and CHD in our study is comparable to some reports in the literature, except for the higher proportion of patients with underlying pulmonary stenosis. Bacterial endocarditis prophylaxis should be emphasized in patients with RHD or pulmonary stenosis.     

Infective Endocarditis in South African Children

The clinical and laboratory findings in 29 children with infective endocarditis over the past 10 years are reviewed retrospectively. Twenty children (70 per cent) had congenital heart disease, five (16 per cent) had rheumatic heart disease, and four (14 per cent) had no underlying cardiac abnormality prior to presentation. Twelve (41 per cent) patients had undergone cardiac surgery prior to developing endocarditis. The most common causative organisms were Staphylococcus aureus, Staphylococcus epidermidis, and viridans streptococci none of which was associated with a significantly greater mortality. There was a high case fatality rate of 35 per cent of children below the age of 6 months and children without an underlying cardiac abnormality were particularly at risk. There is a need for standardization of diagnostic criteria for infective endocarditis to facilitate accurate collaborative epidemiological investigation.     

A 28-year trend of infective endocarditis associated with congenital heart diseases: A single institute experience

BACKGROUND: Infective endocarditis (IE) is still one of the major complications of congenital heart disease and, therefore, prevention has always been an important issue. But there has been no large scale investigation of IE in Japan. METHODS: Clinical and microbiological features in 183 patients with congenital heart diseases complicated with infective endocarditis (IE), which were treated in our institute in the last 28 years, were reviewed. RESULT: During the period, the age distribution of the patients shifted to an older age; 80% were older than 15 years in the latest 7 year period. In the underlying diseases more complex conditions increased, such as the post Rastelli operation. Dental or oral diseases were the major preceding events and Streptococcus was the major pathogen throughout the study periods in the data. CONCLUSION: The result indicates the importance of continuing education for the prevention of IE and oral hygiene especially in adult patients with a risk for IE.     

Two-dimensional echocardiographic assessment of infective endocarditis in children

We examined 11 children with infective endocarditis initially and serially by two-dimensional echocardiography. Nine (82%) of the 11 patients had echocardiographic findings at initial examination compatible with infective endocarditis. These results provided strong evidence in support of the diagnosis before bacteriologic confirmation was available. Congestive heart failure, major emboli, and/or the need for surgical intervention occurred in seven of the nine patients with positive two-dimensional echocardiograms. Echocardiographic evidence of vegetations persisted during antibiotic therapy and resolved slowly during many months. Serial echocardiograms were useful in cases in which obvious valve destruction or marked increase in vegetation size imaged echocardiographically could be combined with clinical evidence of progressive heart failure to support a decision for early surgical intervention. Two-dimensional echocardiography can make important contributions to the diagnosis and management of children with infective endocarditis.     

Neonatal Atrial Fibrillation After Surgical Repair of Tracheoesophageal Fistula With Esophageal Atresia

Atrial fibrillation is rare in childhood that had not been reported in neonates with normal cardiac morphology and function. The authors present a newborn who underwent surgical repair of a tracheoesophageal fistula with esophageal atresia at the age of 2 days and experienced atrial fibrillation 16 days after the procedure. A report of 35 pediatric patients in a single center over a period of 22 years identified atrial fibrillation in children with a variety of ailments including congenital cardiac anomalies before and after corrective surgery, rheumatic valve disease, Marfan's syndrome with mitral regurgitation, infective endocarditis, cardiomyopathy, endocardial fibroelastosis, paroxysmal atrial tachycardia of infants, and cardiac tumors [2]. All these patients had underlying cardiac disease.