Stanford A型主动脉夹层手术死亡风险因素分析

李艳丽; 高晴云; 冯俊波; 张成鑫; 葛圣林

doi:10.16766/j.cnki.issn.1674-4152.002266

Stanford A型主动脉夹层手术死亡风险因素分析

doi: 10.16766/j.cnki.issn.1674-4152.002266

安徽医科大学第一附属医院心脏大血管外科，安徽合肥 230022

基金项目:

安徽省自然科学基金项目 1808085MH279

详细信息

通讯作者:
葛圣林, E-mail: aydgsl@sina.com

中图分类号: R654.2 R543.1
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出版历程
- 收稿日期: 2020-05-16
- 网络出版日期: 2022-03-03

The death risk factors of Stanford A aortic dissection surgery

Department of Cardiovascular Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China

摘要

摘要: 目的收集Stanford A型夹层患者围术期的临床资料以分析探讨夹层术后死亡的独立风险因素。方法收集2012年1月—2020年1月安徽医科大学第一附属医院心脏大血管外科收治共68例Stanford A型主动脉夹层手术患者的围手术期资料，根据患者预后分为术后存活组(50例)和术后死亡组(18例)。收集患者临床资料，对于术前、术中和术后资料进行t/χ²检验，经检验分析差异有统计学意义的术前和术中资料再行logistic多因素回归分析明确夹层手术死亡的风险因素。结果 2组患者术前临床资料的单因素分析可见，左心射血分数(LVEF) < 50%、术前低血压、术前心包积液、术前神经症状、累及冠脉和累及主动脉瓣的对比差异有统计学意义(均P＜0.05)。术中资料分析中，术中乳酸、超滤、尿量以及并行辅助时间的对比差异有统计学意义(均P＜0.05)。上述差异有统计学意义指标的二分类logistic回归分析中可见，术前LVEF < 50%(OR=33.163，P=0.037)和并行辅助时间(OR=1.248，P=0.004)差异有统计学意义。术后资料的风险因素分析中，拔管时间、二次手术、二次插管、苏醒时间、连续肾脏替代治疗、术后乳酸、ICU监护时间差异有统计学意义(均P < 0.05)。结论术前LVEF < 50%和并行辅助时间是A型主动脉夹层术后患者死亡的风险因素。
- A型主动脉夹层 /
- 风险因素 /
- 外科手术 /
- 体外循环
Abstract: Objective To explore the death risk factors after Stanford A aortic dissection surgery based on the perioperative data of patients with Stanford A aortic dissection. Methods A total of 68 patients with Stanford A aortic dissection from January 2012 to January 2020 were enrolled in the Cardiovascular Surgery Department of the First Affiliated Hospital of AnHui Medical University for the retrospective analysis. Based on clinical outcome, patients were divided into survival group (n=50) and death group (n=18). The preoperative, intraoperative and postoperative clinical data was summarized and studied retrospectively. Univariate analysis was performed by t/χ² test and further, multivariate analysis was performed by logistic regression based on significant results from univariate analysis to identify the death risk factors after Stanford A aortic dissection surgery. Results There were significant differences between two groups by univariate analysis for preoperative LVEF < 50%, preoperative hypotension, preoperative pericardial effusion, preoperative neurological disorder, involved coronary arteries, involved aortic valve, intraoperative lactic acid, ultrafiltration, urine volume and supportive cardiopulmonary by pass running time (all P < 0.05). Subsequently, preoperative LVEF < 50% (OR=33.163, P=0.037) and supportive cardiopulmonary bypass running time (OR=1.248, P=0.004) were significant factors by logistic regression analysis. Postoperatively, there were significant differences for extubation time, reoperation, re-intubation, awaking time, CRRT, postoperative lactic acid and ICU stay (all P < 0.05). Conclusion Both preoperative LVEF < 50% and supportive cardiopulmonary bypass running time are the death risk factors of Stanford A aortic dissection surgery.
- Type A aortic dissection /
- Risk factors /
- Surgery /
- Cardiopulmonary bypass

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表 1 2组急性Stanford A型主动脉夹层患者术前资料对比(例)

组别	例数	年龄> 60岁	性别 (男/女，例)	BMI> 28	吸烟史	饮酒史	高血压病史 >10年	服药史	LVEF < 50%	术前低血压	术前心包积液	术前神经症状	累及冠脉系统	累及主动脉瓣
存活组	50	27	30/20	25	33	32	43	38	6	9	7	9	11	14
死亡组	18	12	9/9	11	11	11	15	14	7	11	9	10	12	10
χ²值		0.871	0.540	0.662	0.134	0.051	0.083	0.021	4.572	11.853	9.531	9.274	11.800	4.402
P值		0.351	0.463	0.483	0.714	0.830	0.781	0.832	0.033	0.001	0.002	0.021	0.001	0.042
注：LVEF为左心室射血分数。

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表 2 2组急性Stanford A型主动脉夹层患者术中资料对比

组别	例数	手术>300 min(例)	体外循环> 250 min(例)	主动脉阻断> 180 min(例)	DHCA> 30 min(例)	自动复跳 (例)	输血量> 4 U(例)	失血量> 1 000 mL(例)	乳酸(x ±s， mmol/L)	超滤 (x ±s，mL)	尿量 (x ±s，mL)	并行辅助时间 (x ±s，min)
存活组	50	44	43	40	19	46	45	38	8.29±2.33	3 819.80±599.61	1 199.20±364.89	59.80±11.44
死亡组	18	15	16	13	9	15	16	16	9.98±2.90	3 162.78±446.67	907.78±201.92	83.11±15.55
统计量		0.011^a	< 0.001^a	0.123^a	0.791^a	0.342^a	0.670^a	0.672^a	-2.463^b	4.240^b	3.211^b	-7.061^b
P值		0.920	0.999	0.762	0.363	0.561	0.999	0.412	0.022	< 0.001	0.002	< 0.001
注：DHCA为深低温停循环。^a为χ²值，^b为t值。

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表 3 术后死亡影响因素二分类logistic回归分析

项目	B	SE	Wald χ²	P值	OR值	95% CI
LVEF < 50%	3.501	1.679	4.347	0.037	33.163	1.234~888.912
并行辅助时间(min)	0.222	0.078	8.191	0.004	1.248	1.072~1.453
注：因变量中死亡=1，非死亡=0；自变量中LVEF < 50%=1，LVEF≥50%=0；并行辅助时间以实际值赋值。

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表 4 2组急性Stanford A型主动脉夹层患者术后资料对比

组别	例数	血管活性药物 >96 h(例)	拔管 < 48 h (例)	二次手术 (例)	苏醒时间 < 10 h(例)	CRRT (例)	二次插管 (例)	48 h乳酸 (x±s，mmol/L)	ICU监护 (x±s，h)
存活组	50	15	40	12	40	9	13	4.09±1.60	111.38±18.72
死亡组	18	10	7	11	6	12	10	8.79±2.56	165.61±45.32
统计量		3.721^a	10.482^a	8.144^a	13.173^a	14.691^a	5.170^a	-9.021^b	4.244^b
P值		0.052	0.001	0.001	< 0.001	< 0.001	0.023	< 0.001	< 0.001
注：CRRT为连续性肾脏替代治疗。^a为χ²值，^b为t值。

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