成年房间隔缺损患者并发肺动脉高压影响因素及介入封堵术后即刻肺动脉压力与肺动脉高压关系研究

Influence factors of pulmonary artery hypertension in adult patients with atrial septal defect and the relationship between pulmonary pressure immediately after interventional closure surgery and pulmonary artery hypertension

目的分析成年房间隔缺损(ASD)患者并发肺动脉高压(PAH)的影响因素,探讨患者介入封堵术后即刻肺动脉压力的变化情况及其与术后PAH的关系。方法选取北部战区总医院自2018年1月至2021年1月收治的407例ASD伴不同程度肺动脉压力患者为研究对象。所有患者均接受右心导管检查及封堵治疗。根据术前肺动脉平均压水平不同,将患者分入PAH组(肺动脉平均压≥25 mmHg)和正常组(肺动脉平均压<25 mmHg)。收集并比较两组患者的一般资料,采用Logistic回归分析法分析ASD并发PAH的影响因素,对患者进行随访,观察患者术后即刻肺动脉压力变化及并发PAH的情况。结果正常组285例,PAH组122例。PAH组患者年龄、肺动脉平均压、肺动脉收缩压、缺损直径、红细胞分布宽度、平均血小板体积均大于正常组,差异有统计学意义(P<0.05)。年龄、缺损直径、红细胞分布宽度、平均血小板体积是ASD并发PAH的影响因素(P<0.05);缺损直径是ASD并发PAH的独立危险因素(P<0.05)。PAH组术后即刻恢复正常(肺动脉平均压<25 mmHg)77例(63.1%),轻度PAH(肺动脉平均压25~41 mmHg)30例(24.6%),中度PAH(肺动脉平均压41~55 mmHg)12例(9.8%),重度PAH(肺动脉平均压>55 mmHg)3例(2.5%)。随访1~4年(中位随访时间2年),患者均存活。术后3个月,PAH患者24例(19.7%),其中,20例(16.4%)在术后6个月随访时的肺动脉压力和各心腔大小恢复正常,而另外4例(3.3%)PAH持续存在。术后即刻肺动脉压力恢复正常者和轻度PAH者均无术后持续性PAH存在;术后即刻重度PAH 3例均存在术后持续性PAH;术后即刻中度PAH者肺动脉压力恢复正常和PAH持续存在均有可能。结论年龄、缺损直径、红细胞分布宽度、平均血小板体积是ASD患者并发PAH的影响因素。关闭ASD后导管测量肺动脉压力为重度PAH者术后PAH不可避免地持续存在,若患者术后6个月的肺动脉压力仍然高于正常水平,PAH将持续存在。

Objective To analyze the influencing factors of pulmonary artery hypertension(PAH)in adult patients with atrial septal defect(ASD),and to explore the changes of pulmonary arterial pressure immediately after interventional closure surgery and its relationship with PAH after operation.Methods A total of 407 patients with ASD with varying degrees of pulmonary artery pressure admitted to General Hospital of Northern Theater Command from January 2018 to January 2021 were selected as the study subjects.All patients received right heart catheterization and catheterization.Patients were divided into PAH group(mean pulmonary artery pressure≥25 mmHg)and normal group(mean pulmonary artery pressure<25 mmHg)according to different preoperative mean pulmonary artery pressure levels.The general data of patients in the two groups were collected and compared.The influencing factors of ASD complicated with PAH were analyzed by Logistic regression analysis.The patients were followed up to observe the changes of pulmonary artery pressure immediately after closure and the complications of PAH.Results There were 285 cases in normal group and 122 cases in PAH group.Age,mean pulmonary artery pressure,pulmonary artery systolic pressure,defect diameter,red blood cell distribution width and mean platelet volume in PAH group were higher than those in normal group,the differences were statistically significant(P<0.05).Age,defect diameter,red blood cell distribution width and mean platelet volume were the influencing factors of ASD complicated with PAH(P<0.05).Defect diameter was an independent risk factor for ASD complicated with PAH(P<0.05).In PAH group,77 patients(63.1%)immediately returned to normal(mean pulmonary artery pressure<25 mmHg),30 patients(24.6%)with mild PAH(mean pulmonary artery pressure 25-41 mmHg),12 patients(9.8%)with moderate PAH(mean pulmonary artery pressure 41-55 mmHg),and 3 patients(2.5%)with severe PAH(mean pulmonary artery pressure>55 mmHg).Patients were followed up for 1 to 4 years(median 2 years),and all patients survived.At 3 months postoperatively,24 patients(19.7%)had PAH,of which 20 patients(16.4%)had normal pulmonary artery pressure and lumen size at 6 months postoperatively,while 4 patients(3.3%)had persistent PAH.There was no postoperative persistent PAH in patients with normal pulmonary arterial pressure and mild PAH.All 3 patients with immediate postoperative severe PAH had persistent postoperative PAH.It was possible for pulmonary artery pressure to return to normal and PAH to persist in patients with moderate PAH immediately after closure.Conclusion Age,defect diameter,red blood cell distribution width and mean platelet volume are the influencing factors of PAH after interventional occlusion in ASD patients.It is inevitable that PAH will persist in patients with severe pulmonary arterial pressure measured after ASD closure,and PAH will persist if pulmonary arterial pressure remains higher than normal 6 months after closure.