감염성 심내막염의 합병증과 valve surgery를 고려하는 경우

감염성 심내막염의 합병증

 

감염성 심내막염의 합병증은 septic embolization 때문이며 localized thrombosis, bleeding, infection, 면역 반응과 관련이 있을 수 있습니다. 이 중 가장 합병증 위험이 높은 것은 심내막염으로 인한 심장판막 손상입니다.

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㉠ 심장 합병증 (~50%)으로는 판막 역류, 심부전, 전도 이상이 있습니다. Valve regurgitation을 새롭게 진단을 받은 환자들, mitral valve prolapse와 새로 진단된 chordal rupture가 있는 환자들에서에서는 열이 없더라도 심내막염을 고려해야 합니다.

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㉡ 신경학적 합병증 (~ 40%)으로는 색전성 뇌졸중, 뇌내출혈, 뇌농양이 있습니다.

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㉢ Septic emboli (~25%) 으로는 신장, 비장 및 기타 기관의 경색이 있습니다. 동반된 right-sided endocarditis 환자에서는 septic pulmonary emboli가 관찰될 수 있습니다.

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㉣ 전이성 감염 (예, vertebral osteomyelitis, septic arthritis, splenic, psoas abscess)

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㉤ 전신적 면역 반응 (예, glomerulonephritis). 심내막염 합병증을 진단하기 위해서는 자세한 초기 평가와 연속적인 추적 검사가 필요합니다. 예를 들어, 판막 역류로 인한 울혈성 심부전, 색전성 뇌졸중으로 인한 국소 신경학적 증상, 또는 척추 골수염으로 인한 등 통증 (back pain)의 원인이 감염성 심내막염일 수 있습니다.

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감염성 심내막염에서 valve surgery를 고려하는 경우

㉠ heart failure (HF) symptoms, ㉡ complicated infection, ㉢ persistent infection, ㉣ large vegetations입니다.

㉠ Heart failure (HF) symptoms – For patients with IE-associated valve dysfunction (usually aortic or mitral regurgitation) causing symptoms or signs of HF, we recommend referral for early valve surgery (Grade 1B). The benefits of surgery appear to be greatest among patients with severe valve dysfunction causing HF. Ideally, surgery should be undertaken as soon as signs and symptoms of HF appear and before hemodynamic instability occurs. ​ ㉡ Complicated infection --For patients with paravalvular extension of infection with development of annular or aortic abscess, destructive penetrating lesion (eg, fistula), and/or heart block, we recommend referral for early valve surgery (Grade 1C). --For patients with infection due to a difficult-to-treat pathogen, we suggest referral for early valve surgery. Difficult-to-treat pathogens include fungi and multidrug-resistant organisms (eg, Pseudomonas aeruginosa and vancomycin-resistant Enterococcus) (Grade 2C). We do not consider S. aureus IE an indication for early surgery. ​ ㉢ Persistent infection – We suggest referral for early valve surgery for patients with persistent infection (defined as persistent bacteremia or fever lasting >7 days after initiation of appropriate antibiotic therapy, provided other sites of infection and causes of fever have been excluded) (Grade 2C). ​ ㉣ Large vegetations – Early surgery (within the first week of antibiotic therapy) may reduce the risk of embolism in patients with large vegetations (>10 mm) but criteria for referral for surgery in this setting are controversial. For patients with large vegetations, we perform an individualized risk-benefit assessment comparing early surgery with expectant management based upon multiple factors including the diameter and volume of the vegetation, change in size of the vegetation on appropriate antibiotic therapy, the infecting pathogen, history of prior systemic embolization, likelihood that the patient will soon require valve surgery for another indication (eg, due to severe valve dysfunction), and patient age and life expectancy (which impacts prosthetic valve choice and exposure to long-term risks of prosthetic valve replacement).

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Ref. UpToDate 2024.04.10