Часть 4. Инфекционный эндокардит при врожденном пороке сердца
Популяция детей и взрослых с ВПС расширяется, и это – главный субстрат для ИЭ у молодых пациентов. Однако, наше знание ИЭ в этом окружении ограничено, так как систематических исследований немного и они часто ретроспективны, и смещение выбора, связанное с исследованиями узкоспециализированных центров,
препятсвует широкому применению.
Сообщаемая частота ИЭ при ВПС в 15-140 раз выше, чем в общей популяции (самое высокая оценка возникновения в узкоспециализированных отделениях).361,362 Сообщаемая пропорция ВПС у пациентов с ИЭ изменяется, вероятно из-за смещения выбора, между 2% и 18%,363–365 с постоянным незначительным преобладанием мужчин.58,362,366
Некоторые простые пороки, такой как дефект межпредсердной перегородки типа secundum и порок легочного клапана несут низкий риск ИЭ. Однако, ВПС часто состоит из нескольких сердечных повреждений, каждый из которых дополняет общий риск ИЭ. Например, частота ИЭ значительно выше у пациентов с дефектом межжелудочковой перегородки, когда ассоциированная аортальная регургитация.367
Распределение возбудителей не отличается от такового при приобретенных болезнях сердца, стрептококки и стафилококки являются самыми частыми штаммами.58,362,366
Основные симптомы, осложнения и основание для диагноза не отличаются от ИЭ в общем случае. Однако, правосторонний ИЭ является более частым при ВПС чем при приобретенной болезни сердца. Превосходство
ТЕЕ над TTE не было систематически изучено в этом окружении. Однако, сложная анатомия и присутствие искусственного материала могут уменьшить частоту обнаружения вегетаций и других особенностей ИЭ, таким образом одобряя дополнение ТЕЕ, особенно в группе взрослых.362 Однако, отрицательное исследование не исключает диагноз.
Лечение ИЭ при ВПС следует из общих принципов. Операция на сердце является соответствующей, когда медикаментозная терапия терпит неудачу, когда возникают тяжелые гемодинамические осложнения, и когда есть высокий риск разрушительной септической эмболии.
ИЭ при ВПС несет смертность 4-10%.58,62,362,366 Это лучший прогноз по сравнению с приобретенной болезнью сердца наводит на размышления о более высокой пропорции правосердечного ИЭ.
Первичное профилактика жизненно важна.368 Важность хорошей оральной, дентальной и кожной гигиены была уже подчеркнута, и антибиотическая профилактика обозначена в группах высокого риска, как определено в Разделе E. Однако, есть также образовательная проблема, и понимание риска ИЭ и потребность в профилактических мерах не удовлетворительно распространены в популяции с ВПС.369 Косметический персинг, по меньшей мере затрагивающий язык и слизистые, должен быть запрещен в этой группе.
Хирургическая пластика ВПС часто уменьшает риск ИЭ, если нет остаточных повреждений364,370 Однако, в других случаях, когда имплантирован искусственный клапан, процедура может увеличить общий риск ИЭ. Нет научных данных, оправдывающих сердечную операцию или чрезкожные вмешательства (например, закрытие открытого артериального протока) с единственной целью устранить риск ИЭ.371 Сердечная пластика как вторичная превентивная мера для уменьшения риска рецидива ИЭ была описана, но не была систематически изучена.
Таким образом, ИЭ при ВПС бывает редко и более часто затрагивает правое сердце. Сложная анатомия делает эхокардиографическую оценку трудной. Прогноз лучше чем при других формах ИЭ, со смертностью <10%. Профилактические меры и обучение пациентов имеют особое значение в этой популяции.
Часть 5. Инфекционный эндокардит у пожилых
ИЭ у пожилых (> 70 лет) является все более и более частым и ассоциируется с определенными особенностями.372 Относительная частота ИЭ, затрагивающего пожилых, была 26% в Euro Heart Survey,373 и 33% пациентов были старше 67 лет во Французском регистре.80 Во Французских обзорах частота ИЭ увеличилась между 1991 и 1999 годами среди пациентов > 50 лет и достиг максимума 145 случаев на миллион между 70 и 80-летним возрастом.14
Предыдущие сообщения показали, хотя не совсем убедительно, что ИЭ в преклонном возрасте ассоциируется с плохим прогнозом и с высокой частотой осложнений.166,372,374,375 Это более тяжелое клиническое течение было связано со стертыми начальными симптомами и запоздавшим диагнозом у пожилых людей, и с более высокой частотой более агрессивных возбудителей в этой когорте.166,374,375
У пожилых пациентах желудочнокишечный источник инфекции был описан как ниболее частый. Группа D стрептококков (S. bovis) становится все более и более частая причиной ИЭ, особенно у пожилых,208,376 и ассоциируется с болезнью толстого кишечника, множественным клапанным вовлечением и высоким риком эмболии.208 ….Энтерококковый ИЭ, как показали, также был более частым у старших пациентов.377
Лихорадка - менее частая374 и анемия более частая у пожилых пациентов, вероятно связанная с высокой пропорцией S. bovis ИЭ, при котором повреждения толстого кишечника являются частыми и могут вызвать скрытое кровотечение.208 В некоторых исследованиях вегетации у пожилых, как сообщается, были меньше375 и несли более низкий риск эмболии.372 Не так давно отрицательные культуры крови наблюдались у 16.7% пожилых пациентов с ИЭ.69
Наконец, старший возраст был связан с плохим прогнозом в большинстве недавних исследований.166,372,374,375 Пожилые пациенты меньше лечатся хирургически, вероятно в связи с более высоким операционным риском, связанным с преклонным возрастом и частыми сопутствующими болезнями.378 Однако, хирургическое лечение представляется как разумный выбор у пожилых, с теми же самыми показаниями, что и у молодых пациентов.379
Часть 6. Инфекционный эндокардит во время беременности
Сложность беременной кардиолгической пациентки состоит в изменяющейся сердечно-сосудистой физиологии, которая может симулировать сердечные болезни и спутывать клиническую картину.380,381
Частота ИЭ во время беременности, как сообщали, была 0.006%.382 Поэтому, ИЭ при беременности чрезвычайно редок, и является или осложнением существующего ранее сердечного повреждения или
результатом внутривенного злоупотребления лекарствами. Материнская смертность приближается к 33%, большинство смертельных случаев связаны с СН или эмболией, в то время как эмбриональная смертность составляет 29%.382 Тщательное внимание должно быть обращено на любую беременную женщину с необъясненной лихорадкой и сердечным шумом. Быстрое обнаружение ИЭ и соответствующее лечение важно в сокращении риска и материнской и эмбриональной смертности.382
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