1、感染性心内膜炎Infective Endocarditis,武汉大学人民医院心内科,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,Outlines,Conception Infection of microbes , ecphyma formationSites involved Valves, septal defects, chorda tendineaeCategorizations Acute, subacute Allovalves, prosthetic valve,病因,细菌
2、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,Etiology,Bacterial infection Acute : Staphylococcus aureus Subacute: Streptococcus viridans and others Rarely caused by eumycete or chlamydia infection Intravenous drug abusers: half were caused by staphyloco
3、ccus aureus Prosthetic valve patients: Staphylococcus aureus, Gram-Negative bacillus,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,Pathogenesy,Abnormal haemodynamicsOrganic heart diseaseHigh speed afflux,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
4、性心内膜炎内皮受损高凝状态赘生物很少超过0.5cm,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,诊断 DUKE诊断标准,Major criteriaPositive hemoculture twice Endocardium damage Echocardiogram: ecphyma valve damage newly valvular regur
5、gitation,Minor criteriaHeart disease history or intravenous drug abuseTemperature38CAngio-manifestationImmune reactionBacterial infection Hint from Echocardiogram,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,Treatment,Antibiotic treatment Medication prin
6、ciples：early、sufficient、intravenous、basis on susceptibility testUnclear pathogen: Acute-Staphylococcus aureus Subacute- streptococcusClear pathogen: direct medicationScheme: penicilin , semisynthetic penicillin +aminoglycosides,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,Treatmen
7、t,ComplicationsSurgical therapy excrescent extration,10mm valve ring abscess relapse repeatedly, persistent positive hemoculture valvular regurgitation induced heart failure fungal endocarditis,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
8、术,Prevention,Keep oral healthAntibioticsRisk levelsHigh risk: prosthetic valve, IE history, cyanosis congenital heart disease, heart surgery with abnormal hemodynamicsModerate risk: mitral prolapse with contraflow, retrogression heart diseaseLow risk : mitral prolapse with no contraflow, ASD,预防,手术操作
9、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,Prevention,Careful operation procedureStomato-operationTonsils extrationGastrointestinal operationOperation on gallbladderOperation on urethraColpohysterectomy,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,Prognosis,Untreated patients Acut
10、e 4 weeks Subacute more than 6 monthsNear and long-term prognosis Heart failure, renal failure, embolism Gram-Negative bacillus and eumycete:myocardialabscess,心包疾病,PERICARDIAL DISEASE,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,Outline,Pericardial functionHeart fixationReduce friction betw
11、een heart and periphery tissuePrevent heart disseminateion of inflammation and tumorConstraint heart acute dilatation,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,心包炎（pericarditis）,Most frequently happenedManifestation of general diseaseSpread from tissue in vicinity,St
12、agesAcute Less than 6 weeksSubacute 6 weeks to 6 monthsChronic More than 6 months,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,急性心包炎 （acute pericarditis）,Acute inflammation of epicardial and parietal layer of pericardiumA syndrome with chest pain, pericardial friction ru
13、b and ECG changesCombined with myocarditis and endocarditis,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,Etiology,Infectious pericarditisNon-infectious pericarditisAutoimmunity and hyper-sensibility,acute non-specificity, tumor, AMI, uremia, ra
14、diation injury,Hypersensibility, rheumatism, medicine, traumatic occlusion,Tuberculosis, bacterium, virus, eumycete and others,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,Pathology,Acute fibrinous pericarditis,Pericarditis with effusion,Fibrin, leucocyte and endothelioc
15、yte,Fluid Fibrin serosity Blood serosity Hemorrhagic Maturate,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,Pathology,Fibrinous pericarditisFibrin sedimentum salmon pink linearYellow effusionIn uremia, AMI, acute rheumatic carditis patients,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
16、可引起心包填塞,Pathology,Pericarditis with effusionNo fibrin effusionYellow effusionInflammation cells effusion heartPericardial tamponade,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,Pathology,Adhesive pericarditis Cellulose effusion can be found from epicardium to pericardium, it is typical fibri
17、nous pericarditis,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,Pathology,Acute fibrinous pericarditisThe surface of cardiac pericardium is crude and dry, pericardial friction rub can be heardPericardial friction rubIn uremia, AMI, acute rheumatic carditis patients,病 理,出血性心包炎出血性心包炎的心脏外观呈红色，
18、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,Pathology,Hemorrhagic pericarditisRed and roughMainly caused by tumor and tuberculosis, granuloma can be induced by tuberculosis，constrictive pericarditis can be developed at last,病 理,化脓性心包炎可见黄色渗出物积于心包腔的低处,Pathology,Pyopericarditis Yellow effusion
19、accumulate at the low place of cavitas pericardialis,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,Pathophysiology,Hydropericardium,Cavitas pericardialis pressure,Cardiac output,Diastolic filling,Arterial blood pressure,Increased venous pulse pressure,faster heart rate,Compensation,临床表现：
20、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,Clinical manifestation:symptom,General symptomRelated with primary diseasePrecordialgia Main symptom in fibrious stage Severe pain Related with body position,Oppression symptoms dyspnea cough hoarse voice dysph
21、agiaCardiac tamponade Severe dyspnea Acute circulatory failure and shock,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,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,Clinical manifestation：physical sign,Sign
22、 of hydropericardium Apex beat attenuated or disappearedEnlarged cardiac dullness, low heart sound Pericardial knockEwart sign,Sign of pericardial tamponadeCardiac tachycardiaJugular varicosity Kussmaul sign Paradoxical pulse Congestion of systemic circulation,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、
23、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,Laboratory examination,BiochemistryNon-specificityIncrease lencocyte, neutrophil count and ESR,X-rayDropwise or flask-like heart shadowHeart beat attenuated or disappearedEnlarged heart shadowHelpful in the diagnosis of pulmonary tubercul
24、osis and neoplastie pericarditis,X-ray,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,ECG,ST elevation and dynamic T wave alterationLow-voltage QRSP、QRS、T wave electrical alternationsP-R depression,Cardiac arrhythmia Sinus tachycardia Atrial premature beat, atrial t
25、archycardia, flutter or fibrillation,ECG,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,Echocardiogram,Specific diagnosisFluidity areas opaca in heart peripheryCardiac tamponadeRight atrial and ventricular free wall collapseRight ventricle inner diameter increase in inh
26、aleQuantization: thickness of pericardium,Echocardiogram,Fibious,Effusion,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,Laboratory examination,CT,MRI Thickness of pericardium, quantity and distribution of hydropericardiumQuality of hydroperi-cardiu
27、mPericardial biopsyFor etiological diagnosis,Paracentesis pericardiiQuality of hydropericardium biochemistry biology test pathology testTreatment of cardiac tamponade,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 心包摩擦音,Diagnosis,Etiological diagnosis,Diagno
28、sis,Effusion,Pericarditis,History、paracentesis pericardii、Imageology and biopsy,X-ray、ECG、ECHO,Accompanied with dyspnea, tachycardia, congestion of systemic circulation and cardiac enlargement,Thoracalgia, pericardial rub,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,Nonspecific pericarditis,Up
29、per respiratory infectionPersistent feverSevere chest pain Pericardial rubNegative hemocultureLittle hydropericardium,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,Tuberculous pericarditis,Accompanied with primary tuberculosisLow-grade fever Rare pericardial rubHydropericardium multi
30、plicity，upright，large proportionlymphocyte, bacillus tuberculosis can be found,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,Neoplastie pericarditis,Metastatic tumorSlight thoracalgiaRare pericardial rubHydropericardium multiplicity, upright, large proportionlymphocyte, allotype cells can be found,
