Lesion removal and valve replacement for infective endocarditis

The purpose of infective endocarditis surgery is to completely remove all infected tissue, repair or replace the damaged valve, restore the valve's opening and closing function; and correct other complications, such as aortic aneurysm or interventricular septal perforation. Treating diseases: infective endocarditis Indication Infective endocarditis with lesion clearance and valve replacement is applicable to: 1. Congestive heart failure is a major risk factor for bacterial endocarditis and is therefore an important indication for surgical treatment. Infective endocarditis, once diagnosed, must be given intravenously with effective antibiotics and treated with cardiotonic and diuretic drugs. For example, heart failure is difficult to control, especially when severe ablation is caused by aortic valve destruction. When hemodynamic abnormalities occur, surgery must be performed as soon as possible. 2. Application of antibiotics to treat infection is difficult to control, such as Staphylococcus aureus invading the aortic valve or mitral valve, drug treatment is invalid; Gram-negative bacillary endocarditis, drug treatment is not effective; fungal endocardium Inflammation, the mortality rate of medical treatment is almost 100%. All the above cases need to consider surgical treatment. 3. Repeated occurrence of systemic arterial embolization in patients with echocardiography, often showing tissue damage caused by neoplasms or infections, should also be surgical treatment. 4. Infective endocarditis causes periorbital abscess or myocardial abscess, cardiac conduction system block, aortic sinus rupture or ventricular septal perforation and other complications, surgical removal of lesions, repair of defects, removal and replacement of diseased valves, Completely cured. 5. The endocarditis of the right heart system generally has a good effect on medical treatment, but if it causes pulmonary embolism, echocardiography reveals that there are sputum, etc., should be treated surgically. Contraindications Bacterial endocarditis, especially fungal infections, causing severe congestive heart failure and important organ dysfunction; combined with multiple systemic embolism, especially cerebral embolism caused by coma and limb paralysis; or cardiogenic shock or even When it is caused by acute pulmonary edema, it is not suitable for surgery. Preoperative preparation Generally, it should be prepared according to the cardiopulmonary bypass surgery. However, in patients with infective endocarditis, the acute phase is generally in a critical or high-heat state, accompanied by cardiac insufficiency or heart failure. Therefore, the following special preparations should be made. 1. The application of antibiotics should be based on the drug sensitivity of the infected strain, and effective antibiotics should be used. In order to ensure the absorption of the drug and maintain the effective bactericidal concentration in the blood, it must be administered by intravenous injection or drip. However, the application of antibiotics must be based on the treatment effect and the condition. Generally, antibiotics cannot be controlled for several days to one week, that is, surgery should be used. 2. Improve nutritional status In addition to oral high-nutrition foods, patients with anemia should receive a small amount of fresh blood, plasma or albumin intermittently, and a small amount of hormones in a short period of time to improve the patient's stress, promote the patient's metabolic status, and enhance resistance. . 3. Treatment of heart failure Congestive heart failure is the main cause of death in patients with endocarditis, especially the infection on the basis of normal valve is different from the heart failure caused by chronic rheumatic valvular disease, because most patients have no myocardial disease before onset. Compensatory hypertrophy, due to inflammatory destruction of the valve, causing acute severe insufficiency, the left ventricle is difficult to withstand a sudden increase in capacity load, and severe heart failure occurs. Therefore, it is necessary to use cedilan and furosemide intravenous injection, and intravenous infusion of vasodilators to reduce the anterior and posterior load of the heart, combined with intravenous infusion of milrinone, dopamine or dobutamine to improve myocardial Contraction force and stroke volume. Surgical procedure Infective endocarditis occurs mostly in the aortic valve, followed by the mitral valve, and sometimes the tricuspid valve and the pulmonary valve can also be affected. Therefore, the surgical procedure will vary depending on the affected valve. However, aortic valve endocarditis is more complicated and difficult to operate. The main point of surgery is to completely remove the infected lesions, replace the artificial valve, and correct the hemodynamic abnormalities. Conventional establishment of extracorporeal circulation and injection of cardiac arrest fluid, after the heart stops, ascending aortic incision. The location and extent of the lesion, as well as the degree of damage to the leaflets, annulus, and adjacent sites were examined in detail. If only the leaflets are damaged, remove the valve leaflets and their neoplasms, then rinse the heart chamber thoroughly with a low concentration of organic iodine or a sterile solution. Use a sutured sutured annulus with a septum. Care should be taken when suturing, to avoid tearing of the annulus tissue. If the annulus is weak due to inflammatory changes, if there is no coronary flap, the suture can pass through the aortic wall. The piece is placed outside the wall. After sewing, pass through the artificial valve suture ring, and then send the valve seat ring knotted. Bacterial endocarditis, which forms an abscess near the annulus, is a characteristic change in aortic valve endocarditis. Therefore, it should be removed according to its different parts. The surgical procedure is as follows. 1. Abdominal aneurysm abscess After the diseased leaflets were removed, the abscess was opened, the pus was removed, the necrotic tissue of the abscess wall was removed, and the low-concentration organic iodine solution was repeatedly washed, and the annulus was sutured to fix the artificial valve. After suturing the artificial valve suture with 3-0 polyester suture, the outer aortic wall is padded with a gasket; the area adjacent to the pulmonary artery, the suture passes through the pulmonary artery wall, and then sewed back into the aorta, and then Knotted through the upper part of the seam loop. The suture should be operated under direct vision on the posterior wall of the aortic root, and the knot must be secure to avoid bleeding that is difficult to handle. 2. Aortic valve abscess A large abscess is formed on the aortic valve and protrudes out of the aortic wall; it is a tumor-like change. Surgery should remove the diseased valve and the damaged aortic wall and its abscess to completely remove the inflammatory lesions and necrotic tissue seen by the naked eye. The aortic wall of the defect was repaired with an artificial patch and an aortic valve replacement was performed. 3. Peri-valvular localized abscess The left coronary valve of the aortic valve is connected to the anterior flap of the mitral valve below the non-crown valve. Aortic valve endocarditis, an abscess around the annulus can invade the union of the aortic valve and the mitral valve. To remove the fissure-like defect formed during the abscess in this area, a non-invasive needle with a gasket can be used to insert the needle from the lower edge of the defect, and the needle is inserted from the upper edge of the defect, and the suture is intermittently sutured, but the knot is not tied. The artificial valve suture ring can be directly sewn, the suture of the aortic valve is completely sewn, the valve seat ring is knotted, and the defect is closed once. However, special attention should be paid to the fact that the tension should not be too large. For example, bleeding after the valve is replaced, and suturing and repairing is extremely difficult. Sometimes the artificial valve needs to be removed and sutured. However, it is not appropriate to suture the artificial valve suture ring at the same time. After the defect is repaired, the annulus suture is placed. If the area of the abscess is large in this part, and the defect is large after the lesion is removed, it is difficult to directly match the patch. Then the polyester patch is used for repair, and then the aortic annulus suture is sutured. After the defect is repaired, the suture is directly sewn on the polyester patch. . 4. Aortic root ring abscess Sometimes aortic valve endocarditis, the aortic sinus adjacent to the annulus is ruptured by the inflammatory lesions, and the valve and annulus are also severely damaged. The valve, annulus, and the ascending aorta should be removed, and the ascending aorta of the same species with cryopreservation should be used for transplantation. The left and right coronary arteries are then transplanted. In the proximal aortic anastomosis, a polyester patch should be placed under the anastomotic suture to wrap around the anastomosis for a week to strengthen the anastomosis to avoid anastomotic tear due to tissue edema. complication Periplasm leakage It is the main complication after bacterial endocarditis valve replacement. The main reason for the occurrence is that the inflammatory lesions are not completely removed, and the suture splits the annulus tissue. Therefore, prevention should be emphasized for the above reasons, but the incidence is still higher than that of other lesions. For surgical treatment of paravalvular leaks, see postoperative recurrent valvular disease. 2. Acute heart failure The main cause of heart failure after infective endocarditis surgery is the inflammatory lesions of the preoperative myocardium and the severe insufficiency of the valve destruction. The normal myocardium is difficult to tolerate the sudden increase in the volume load of a large amount of reflux. Followed by intraoperative myocardial ischemia and hypoxia injury. If the early postoperative treatment is not appropriate, the excess of colloidal fluid is added, and the volume load of the heart is more important. In such patients, once heart failure occurs, it is difficult to treat, and can cause multiple organ failure, which can promote recurrence of infection and sepsis. Therefore, the mortality rate is high.