感染性心内膜炎的定义和诊疗

1、感染性心内膜炎Infective Endocarditis感染性心内膜炎的定义和诊疗概述概念 微生物感染 赘生物形成受累部位 瓣膜 间隔缺损部位 腱索 心壁内膜分类 急性（数天） 亚急性（数周至数月） 自体瓣膜 人工瓣膜 静脉药瘾者 感染性心内膜炎的定义和诊疗OutlinesConception Infection of microbes , ecphyma formationSites involved Valves, septal defects, chorda tendineaeCategorizations Acute, subacute Allovalves, prosthetic

2、valve感染性心内膜炎的定义和诊疗病因细菌感染为主 急性 金黄色葡萄球菌 亚急性 草绿色链球菌 菌谱复杂 真菌 衣原体少见 静脉药物滥用者 金黄色葡萄球菌 50% 人工瓣膜 凝固酶阴性葡萄球菌 金黄色葡萄球菌 革兰氏阴性杆菌感染性心内膜炎的定义和诊疗EtiologyBacterial infection Acute : Staphylococcus aureus Subacute: Streptococcus viridans and others Rarely caused by eumycete or chlamydia infection Intravenous drug abuser

3、s: half were caused by staphylococcus aureus Prosthetic valve patients: Staphylococcus aureus, Gram-Negative bacillus感染性心内膜炎的定义和诊疗发病机制血流动力学因素亚急性多见于器质性心脏病赘生物位于血流从高压腔到低压腔形成湍流和射流的下游高速射流冲击心脏或大血管内膜处并致损伤感染性心内膜炎内面观赘生物 MR时二尖瓣心房面 AR时主动脉瓣心室面感染性心内膜炎的定义和诊疗PathogenesyAbnormal haemodynamicsOrganic heart diseaseHi

4、gh speed afflux感染性心内膜炎的定义和诊疗发病机制典型的非细菌性血栓性心内膜炎非细菌性血栓性心内膜炎非细菌性血栓性心内膜炎内皮受损高凝状态赘生物很少超过0.5cm感染性心内膜炎的定义和诊疗Pathogenesy典型的非细菌性血栓性心内膜炎非细菌性血栓性心内膜炎Non-bacterial embolic endocarditisEndothelial damageHypercoagulabale stateEcphyma38C血管表现免疫学反应细菌学依据超声心动图提示21+35感染性心内膜炎的定义和诊疗诊断 DUKE诊断标准 Major criteriaPositive hemoc

5、ulture twice Endocardium damage Echocardiogram: ecphyma valve damage newly valvular regurgitationMinor criteriaHeart disease history or intravenous drug abuseTemperature38CAngio-manifestationImmune reactionBacterial infection Hint from Echocardiogram21+35感染性心内膜炎的定义和诊疗治疗抗生素的治疗 用药原则：早期、充分、静脉用药、根据药敏试验选

6、用药物病原体不明 急性 金黄色葡萄球菌 亚急性 链球菌已知病原体 针对用药方案 青霉素 半合成青霉素 +氨基糖甙类感染性心内膜炎的定义和诊疗TreatmentAntibiotic treatment Medication principles：early、sufficient、intravenous、basis on susceptibility testUnclear pathogen: Acute-Staphylococcus aureus Subacute- streptococcusClear pathogen: direct medicationScheme: penicilin ,

7、 semisynthetic penicillin +aminoglycosides感染性心内膜炎的定义和诊疗治疗并发症的治疗外科治疗 赘生物的摘除 10mm 瓣环脓肿 反复复发 血培养持续阳性 瓣膜严重反流致心力衰竭 真菌性心内膜炎感染性心内膜炎的定义和诊疗TreatmentComplicationsSurgical therapy excrescent extration,10mm valve ring abscess relapse repeatedly, persistent positive hemoculture valvular regurgitation induced hea

8、rt failure fungal endocarditis感染性心内膜炎的定义和诊疗预防保持良好的口腔卫生预防性应用抗生素 患者的危险分层高危患者 人工瓣膜 既往IE病史 发绀性先心 心脏手术伴血流动力学异常中危患者 二脱伴反流 老年人退行性心脏病低危或无危险患者 二脱无反流 房缺 原有心脏手术感染性心内膜炎的定义和诊疗PreventionKeep oral healthAntibioticsRisk levelsHigh risk: prosthetic valve, IE history, cyanosis congenital heart disease, heart surgery

9、with abnormal hemodynamicsModerate risk: mitral prolapse with contraflow, retrogression heart diseaseLow risk : mitral prolapse with no contraflow, ASD感染性心内膜炎的定义和诊疗预防手术操作的分类会引起牙龈或粘膜出血的口腔操作扁桃体摘除术胃肠道手术胆囊手术尿道手术阴道子宫切除术感染性心内膜炎的定义和诊疗PreventionCareful operation procedureStomato-operationTonsils extrationGa

10、strointestinal operationOperation on gallbladderOperation on urethraColpohysterectomy 感染性心内膜炎的定义和诊疗预后未治疗的患者 急性 4周 亚急性 超过6月近期及远期预后 心力衰竭 肾功能衰竭 栓塞 革兰氏阴性杆菌和真菌 心肌脓肿 感染性心内膜炎的定义和诊疗PrognosisUntreated patients Acute 4 weeks Subacute more than 6 monthsNear and long-term prognosis Heart failure, renal failure,

11、 embolism Gram-Negative bacillus and eumycete:myocardialabscess感染性心内膜炎的定义和诊疗心包疾病PERICARDIAL DISEASE感染性心内膜炎的定义和诊疗概 述心包的正常功能心脏在胸腔内的固定减少心脏与周围组织的摩擦阻止炎症和肿瘤向心脏播散限制心脏的急性扩张感染性心内膜炎的定义和诊疗 OutlinePericardial functionHeart fixationReduce friction between heart and periphery tissuePrevent heart disseminateion of

12、 inflammation and tumorConstraint heart acute dilatation感染性心内膜炎的定义和诊疗心包炎（pericarditis）最常见的心包病变全身疾病表现之一由邻近组织病变蔓延而来分期急性期 6周以内亚急性期 6周至6月慢性期 6月以上感染性心内膜炎的定义和诊疗心包炎（pericarditis）Most frequently happenedManifestation of general diseaseSpread from tissue in vicinityStagesAcute Less than 6 weeksSubacute 6 wee

13、ks to 6 monthsChronic More than 6 months感染性心内膜炎的定义和诊疗急性心包炎 （acute pericarditis）心包脏层和壁层急性炎症以胸痛、心包摩擦音和心电图改变为特征的综合征可同时合并心肌炎和心内膜炎感染性心内膜炎的定义和诊疗急性心包炎 （acute pericarditis）Acute inflammation of epicardial and parietal layer of pericardiumA syndrome with chest pain, pericardial friction rub and ECG changesCo

14、mbined with myocarditis and endocarditis感染性心内膜炎的定义和诊疗病 因 感染性心包炎非感染性心包炎自体免疫性或过敏性急性非特异性、肿瘤性、急性心肌梗死性、尿毒症性、放射损伤性、邻近器官引起过敏性、风湿性疾病、药物性、创伤性结核性、细菌性、病毒性、真菌性、其他感染性心内膜炎的定义和诊疗 EtiologyInfectious pericarditisNon-infectious pericarditisAutoimmunity and hyper-sensibilityacute non-specificity, tumor, AMI, uremia, r

15、adiation injuryHypersensibility, rheumatism, medicine, traumatic occlusionTuberculosis, bacterium, virus, eumycete and others感染性心内膜炎的定义和诊疗病 理急性纤维蛋白性心包炎（干性） 渗出性心包炎（湿性）纤维蛋白、白细胞和内皮细胞液体明显增多 浆液纤维蛋白性 浆液血性 出血性 化脓性渗液感染性心内膜炎的定义和诊疗PathologyAcute fibrinous pericarditis Pericarditis with effusion Fibrin, leucoc

16、yte and endotheliocyteFluid Fibrin serosity Blood serosity Hemorrhagic Maturate感染性心内膜炎的定义和诊疗病 理纤维素性心包炎形态纤维蛋白的沉积物 淡红色 线状黄色渗出液见于尿毒症、急性心肌梗塞、急性风湿性心脏炎感染性心内膜炎的定义和诊疗PathologyFibrinous pericarditisFibrin sedimentum salmon pink linearYellow effusionIn uremia, AMI, acute rheumatic carditis patients感染性心内膜炎的定义和

17、诊疗病 理浆液性心包炎形态未见纤维蛋白渗出物黄色渗出液炎性细胞 液体中 心脏表面以积液为主，少数情况下可引起心包填塞感染性心内膜炎的定义和诊疗PathologyPericarditis with effusionNo fibrin effusionYellow effusionInflammation cells effusion heartPericardial tamponade感染性心内膜炎的定义和诊疗病 理粘连性心包炎 从心外膜表面直到心包可见细小的纤维素性渗出物的沉积物，这是纤维素性心包炎的典型表现 感染性心内膜炎的定义和诊疗PathologyAdhesive pericarditi

18、s Cellulose effusion can be found from epicardium to pericardium, it is typical fibrinous pericarditis感染性心内膜炎的定义和诊疗病 理急性纤维素性心包炎心包膜表面粗糙，干燥，由此产生心包摩擦音见于尿毒症、急性心肌梗死、急性风湿性心脏炎感染性心内膜炎的定义和诊疗PathologyAcute fibrinous pericarditisThe surface of cardiac pericardium is crude and dry, pericardial friction rub can

19、be heardPericardial friction rubIn uremia, AMI, acute rheumatic carditis patients感染性心内膜炎的定义和诊疗病 理出血性心包炎出血性心包炎的心脏外观呈红色，表面粗糙大多由转移性肿瘤和结核引起，结核还可引起肉芽肿性心包炎从而导致心包钙化，最终发展成缩窄性心包炎感染性心内膜炎的定义和诊疗PathologyHemorrhagic pericarditisRed and roughMainly caused by tumor and tuberculosis, granuloma can be induced by tub

20、erculosis，constrictive pericarditis can be developed at last感染性心内膜炎的定义和诊疗病 理化脓性心包炎可见黄色渗出物积于心包腔的低处感染性心内膜炎的定义和诊疗PathologyPyopericarditis Yellow effusion accumulate at the low place of cavitas pericardialis感染性心内膜炎的定义和诊疗病理生理心包积液心包腔压力上升心搏出量减少舒张期充盈减少动脉血压下降静脉压增高收缩力增强心率增快代偿感染性心内膜炎的定义和诊疗PathophysiologyHydrop

21、ericardiumCavitas pericardialis pressureCardiac outputDiastolic fillingArterial blood pressureIncreased venous pulse pressure,faster heart rateCompensation感染性心内膜炎的定义和诊疗临床表现：症状全身症状 与病因相关心前区疼痛 纤维蛋白性阶段主要症状 疼痛剧烈 与体位有关 心包积液压迫症状 呼吸困难 咳嗽 声音嘶哑 吞咽困难心脏压塞 严重呼吸困难 急性循环衰竭和休克感染性心内膜炎的定义和诊疗Clinical manifestation:sym

22、ptomGeneral symptomRelated with primary diseasePrecordialgia Main symptom in fibrious stage Severe pain Related with body position Oppression symptoms dyspnea cough hoarse voice dysphagiaCardiac tamponade Severe dyspnea Acute circulatory failure and shock感染性心内膜炎的定义和诊疗临床表现：体征心包摩擦音搔刮样，粗糙，高频，与心音无关胸骨左缘第

23、三、四肋间最明显深吸气、坐位前倾时增强积液量增多时，减弱或消失急性纤维蛋白性心包炎的典型体征感染性心内膜炎的定义和诊疗临床表现：体征心包积液体征 心尖搏动减弱或消失心浊音界向两侧扩大，心音低而遥远心包叩击音（pericardial knock）Ewart征 心包填塞体征心动过速颈静脉怒张 Kussmaul征 奇脉 体循环淤血感染性心内膜炎的定义和诊疗Clinical manifestation：physical signSign of hydropericardium Apex beat attenuated or disappearedEnlarged cardiac dullness, l

24、ow heart sound Pericardial knockEwart sign Sign of pericardial tamponadeCardiac tachycardiaJugular varicosity Kussmaul sign Paradoxical pulse Congestion of systemic circulation感染性心内膜炎的定义和诊疗实验室检查 生化检查无特异性感染性心包炎常有 白细胞计数 中性粒细胞明显升高、血沉加快X线检查心影呈水滴状或烧瓶状透视下心脏搏动减弱或消失肺部无明显充血而心影显著增大有助于肺结核或肿瘤性心包炎的诊断感染性心内膜炎的定义和诊

25、疗Laboratory examination BiochemistryNon-specificityIncrease lencocyte, neutrophil count and ESRX-rayDropwise or flask-like heart shadowHeart beat attenuated or disappearedEnlarged heart shadowHelpful in the diagnosis of pulmonary tuberculosis and neoplastie pericarditis感染性心内膜炎的定义和诊疗X-ray感染性心内膜炎的定义和诊

26、疗心电图ST段呈弓背向下抬高伴T波动态改变肢导联QRS波群低电压P、QRS、T波电交替P-R段压低心律失常 窦性心动过速 房早、房速、房扑或房颤、房室传导阻滞感染性心内膜炎的定义和诊疗ECGST elevation and dynamic T wave alterationLow-voltage QRSP、QRS、T wave electrical alternationsP-R depression Cardiac arrhythmia Sinus tachycardia Atrial premature beat, atrial tarchycardia, flutter or fibri

27、llation 感染性心内膜炎的定义和诊疗ECG感染性心内膜炎的定义和诊疗超声心动图特异性诊断价值心脏外周均匀存在液性暗区心脏压塞的超声表现舒张期右房和右室游离壁塌陷吸气时右室内径增大左心室内径缩小和室间隔左移定量，心包厚度感染性心内膜炎的定义和诊疗EchocardiogramSpecific diagnosisFluidity areas opaca in heart peripheryCardiac tamponadeRight atrial and ventricular free wall collapseRight ventricle inner diameter increase

28、in inhaleQuantization: thickness of pericardium感染性心内膜炎的定义和诊疗EchocardiogramFibiousEffusion感染性心内膜炎的定义和诊疗实验室检查CT或磁共振显像 心包厚度和心包积液量及分布情况帮助分辨积液性质心包活检用于病因诊断 心包穿刺 心包液体的性质 生化检查 生物学检查 病理学检查心脏压塞或治疗需要在超声定位指导下进行 感染性心内膜炎的定义和诊疗Laboratory examinationCT,MRI Thickness of pericardium, quantity and distribution of hydr

29、opericardiumQuality of hydroperi-cardiumPericardial biopsyFor etiological diagnosisParacentesis pericardiiQuality of hydropericardium biochemistry biology test pathology testTreatment of cardiac tamponade感染性心内膜炎的定义和诊疗诊 断 病因学诊断心包炎诊断心包炎伴渗液心包炎可能病史、心包穿刺、影像学和活检X线检查、心电图、超声心动图同时伴有呼吸困难、心动过速体循环淤血和心脏增大的体征胸痛 心

30、包摩擦音感染性心内膜炎的定义和诊疗Diagnosis Etiological diagnosisDiagnosisEffusion Pericarditis History、paracentesis pericardii、Imageology and biopsyX-ray、ECG、ECHOAccompanied with dyspnea, tachycardia, congestion of systemic circulation and cardiac enlargementThoracalgia, pericardial rub感染性心内膜炎的定义和诊疗感染性心内膜炎的定义和诊疗感染性

31、心内膜炎的定义和诊疗非特异性心包炎：主要特点 上呼吸道感染前驱症状持续发热胸痛剧烈心包摩擦音明显血培养阴性心包积液量较少感染性心内膜炎的定义和诊疗Nonspecific pericarditisUpper respiratory infectionPersistent feverSevere chest pain Pericardial rubNegative hemocultureLittle hydropericardium感染性心内膜炎的定义和诊疗结核性心包炎 ：主要特点常伴原发性结核病灶 低热 心包摩擦音少有心包积液常大量，多为血性，淋巴细胞比例高，可找到结核杆菌感染性心内膜炎的定义和

32、诊疗Tuberculous pericarditisAccompanied with primary tuberculosisLow-grade fever Rare pericardial rubHydropericardium multiplicity，upright，large proportionlymphocyte, bacillus tuberculosis can be found感染性心内膜炎的定义和诊疗肿瘤性心包炎 ：主要特点转移性肿瘤多见 胸痛不明显心包摩擦音少见心包积液常大量，多为血性，淋巴细胞比例高，可见异型细胞感染性心内膜炎的定义和诊疗Neoplastie peric

33、arditisMetastatic tumorSlight thoracalgiaRare pericardial rubHydropericardium multiplicity, upright, large proportionlymphocyte, allotype cells can be found感染性心内膜炎的定义和诊疗化脓性心包炎 ：主要特点原发感染病灶和败血症高热 胸痛不明显心包摩擦音少白细胞计数明显增高 心包积液较多，脓性，主要为中性粒细胞，可找到化脓性细菌 感染性心内膜炎的定义和诊疗Purulent pericarditisPrimary infectionHyperp

34、yrexia Slight thoracalgiaRare pericardial rubIncreased leucocytes count Hydropericardium multiplicity, purulence, large proportion neutrophil, bacterium can be found感染性心内膜炎的定义和诊疗风湿性心包炎 ：主要特点全心炎的一部分，伴风湿热其他表现 不规则轻中度发热 常有胸痛 心包摩擦音常有心包积液量少，多呈草绿色，主要为中性粒细胞 感染性心内膜炎的定义和诊疗Rheumatic pericarditisPart of pancard

35、itis, accompanied with the other manifestation of rheumatic fever Irregular moderate fever Thoracalgia Pericardial rub Few, prasinous hydropericardium, large proportion neutrophil. 感染性心内膜炎的定义和诊疗心脏损伤后综合征 ：主要特点手术或心肌梗死等心脏损伤病史 常有发热常有胸痛心包积液较少，草黄色或血性，淋巴细胞较多可复发 感染性心内膜炎的定义和诊疗Heart injury syndromeHistory of

36、operation ,myocardial infarction or heart injury FeverThoracalgiaFew prasinous or upright hydropericardiumRelapse 感染性心内膜炎的定义和诊疗鉴别诊断胸痛为主要症状 急性心肌梗死患者年龄较大无上呼吸道感染史心电图有异常Q波、ST段呈弓背向上抬高和T波倒置并呈动态演变血清心肌标志物或心肌酶学指标升高 疼痛主要在上腹部急腹症病史、体格检查 以呼吸困难、心界扩大为主要表现 心肌病、先心病等体征、X线检查、心电图和超声心动图 感染性心内膜炎的定义和诊疗Differential diagnos

37、isThoracalgia AMIOld patients No history of upper respiratory infectionECG: Q wave, ST elevation ,T wave depression and dynamic alteration Myocardium marker and cardiac creatase Pain in epigastAcute abdomen History, medical examinationDyspnea Cardiomyopathy, congenital heart diseaseSign, X-ray, ECG,

38、 ECHO 感染性心内膜炎的定义和诊疗结核性心包炎早期、足量、联合抗结核药物治疗化脓性心包炎 足量有效的抗生素心包穿刺排脓 心包腔内注入抗生素非特异性心包炎和心脏损伤综合征无特异性治疗应用肾上腺皮质类固醇考虑秋水仙碱12mg/天风湿性心包炎加强抗风湿治疗肾上腺皮质类固醇反应较好治 疗病因治疗缓解心脏压塞对症治疗感染性心内膜炎的定义和诊疗结核性心包炎早期、足量、联合抗结核药物治疗化脓性心包炎 足量有效的抗生素心包穿刺排脓 心包腔内注入抗生素Nonspecific pericarditis and heart injury syndrome No specific treatment Adrena

39、l cortical steroid Rheumatic pericarditis Anti-rheumatism treatmentadrenal cortical steroidTreatmentEtilogical treatmentCardiac tamponade reliefSymptomatic treatment感染性心内膜炎的定义和诊疗治 疗心包穿刺 超声定位指导 X线透视下进行心包切开引流术 化脓性心包炎心包切除术 非特异性心包炎有反复发作者 穿刺点左侧第五肋间心浊音界内侧约12厘米处 病人取坐位胸骨剑突与左肋缘相交处 病人取半坐位迷走性低血压反应 阿托品病因治疗缓解心脏压

40、塞对症治疗感染性心内膜炎的定义和诊疗TreatmentParacentesis Ultrasound locatization X-rayPericardium incision and drainage purulent pericarditisPericardectomy Nonspecific pericarditis recurrent attacks ParacentesisFifth ribEnsiform process of sternum intersect with left costal border Seated leaning-forward positionHypo

41、tension response -atropineEtilogical treatmentCardiac tamponade reliefSymptomatic treatment感染性心内膜炎的定义和诊疗治 疗住院观察 卧床休息至发热及胸痛症状消失水肿者 给予利尿剂 加强支持治疗胸痛剧烈者非甾体类抗炎药物 阿斯匹林600mg，每34小时1次 消炎痛25mg50mg，每6小时一次吗啡或左侧星状神经节封闭病因治疗缓解心脏压塞对症治疗感染性心内膜炎的定义和诊疗治 疗Hospitalization Complete bed rest until the disappearance of fever

42、 and thoracalgiaEdema patients Diuretic Supportive treatmentSevere thoracalgia non-steroid anti-inflammatory drug (NSAID): Aspirin Indomethacin Morphine Left ganglion stellare blockageEtilogical treatmentCardiac tamponade reliefSymptomatic treatment感染性心内膜炎的定义和诊疗预 后取决于病因结核性或化脓性心包炎 经过及时有效的治疗痊愈 缩窄性心包炎非

43、特异性心包炎患者易复发并发于急性心肌梗死、恶性肿瘤或结缔组织病者预后较差 感染性心内膜炎的定义和诊疗PrognosisDepends on etiological factorTuberculous and purulent pericarditis: healing after promptly treatment Constrictive pericarditisNonspecific pericarditis usually relapsePatients accompanied with AMI, malignant tumor or connective tissue disease

44、 may have bad prognosis 感染性心内膜炎的定义和诊疗缩窄性心包炎病因:结核最常见感染性心内膜炎的定义和诊疗临床表现：症状心包积液压迫症状 呼吸困难 咳嗽 声音嘶哑 吞咽困难心脏压塞 严重呼吸困难 急性循环衰竭和休克感染性心内膜炎的定义和诊疗Clinical manifestation:symptomOppression symptoms dyspnea cough hoarse voice dysphagiaCardiac tamponade Severe dyspnea Acute circulatory failure and shock感染性心内膜炎的定义和诊疗诊断

45、与鉴别诊断诊断并不困难需要与限制性心肌病鉴别感染性心内膜炎的定义和诊疗治疗手术治疗感染性心内膜炎的定义和诊疗CASE 1 Name: Wang Age: 42 years Sex: male Chief complaint: Chest pain and fever for 1 dayPresent history: He had consistent severe chest pain one day before without any cause, the pain aggravated during cough and deep breath, radiating to left shoulder, accompanied with fever、palpitation、dyspnea、sweating and coldness in the skin. He felt fatigue after slight move