影响动脉转位术手术死亡的危险因素分析

Risk Factors for Mortality in the Arterial Switch Operation

目的探讨动脉转位术(arterial switch operation,ASO)手术死亡的危险因素,以提高手术成功率,降低手术死亡率。方法2001年1月1日至2007年12月31日期间在阜外心血管病医院行ASO208例,男157例,女51例;年龄6 h至17岁,中位年龄90 d;体重3～43 kg,中位体重5 kg。大动脉转位(TGA)/室间隔缺损(VSD)127例,TGA/室间隔完整(IVS)或合并VSD直径<5 mm81例。冠状动脉分布正常(1LCx2R)151例,单冠状动脉畸形15例,壁内走行6例,冠状动脉分布反位36例。收集所有患者术前、术中和术后的临床资料,建立数据库,行单因素和logistic多因素分析影响ASO手术死亡的危险因素。结果围术期死亡24例(11.54%),死于术后感染合并多器官功能衰竭12例,低心排血量综合征10例,肺动脉高压危象1例,脑部并发症1例。其中2001～2005年手术死亡20例(18.30%),2006～2007年手术死亡4例(4.00%),后者手术死亡率较前者明显降低(P<0.05)。单因素分析结果:死亡患者体外循环时间明显长于生存患者(236±93 min vs.198±50 min,P=0.002),冠状动脉分布异常(33.3%vs.6.5%,P=0.000)及术中发生冠状动脉事件(33.3%vs.2.2%,P=0.000)的比率明显高于生存患者;logistic回归多因素分析结果:手术年代早(OR=7.463,P=0.003)、冠状动脉分布异常(OR=6.303,P=0.005)及术中发生冠状动脉事件(OR=17.312,P=0.000)是ASO围术期死亡的主要危险因子。结论ASO有明显的学习曲线,手术年代早、冠状动脉分布异常、术中对冠状动脉处理不当是影响ASO死亡的主要危险因子。

Objective To analyze risk factors for peri-operative mortality in the arterial switch operation（ASO）,in order to provide better operation and decrease the mortality rate.Methods We enrolled 208 ASO patients including 157 males and 51 females at Fu Wai Hospital between January 1,2001 and December 31,2007.The age ranged from 6 h to 17 years with the median age of 90 d and the weight ranged from 3 kg to 43 kg with the median weight of 5 kg.Among the patients,127 had transposition of great artery（TGA） with ventricular septal defect（VSD）,and 81 patients had TGA with intact ventricular septum（IVS） or with the diameter of VSD smaller than 5 mm.Coronary anatomy was normal（1LCX2R） in 151 patients and abnormal in the rest including 15 patients with single coronary artery,6 with intramural and 36 with inverse coronary artery.Preoperative,peri-operative and postoperative clinical data of all patients were collected to establish a database which was then analyzed by univariate analysis and multivariate logistic regression analysis to find out the risk factors for mortality in ASO.Results There were 24 peri-operative deaths（11.54%） in which 12 died of postoperative infection with multiple organ failure（MOF）,10 died of low cardiac output syndrome,1 died of pulmonary hypertension,and 1 died of cerebral complications.Among them,20 patients（18.30%） died in early years from 2001 to 2005,while only 4（4.00%） died in the time period from 2006 to 2007,which was a significant decrease compared with the former period（P0.05）.The univariate analysis revealed that cardiopulmonary bypass（CPB） time was significantly longer in the death group than in the survival group（236±93 min vs.198±50 min,P= 0.002）,and occurrence of major coronary events（33.3% vs.2.2%,P=0.000） and unusual coronary artery patterns（33.3% vs.6.5%,P=0.000） were much more in the death group than in the survival group.Multivariate logistic regression analysis showed that early year of operation（OR=7.463,P=0.003）,unusual coronary artery patterns（OR=6.303,P=0.005） and occurrence of major