主动脉夹层手术后肝功能不全发生的相关危险因素分析

The relative risk factors analysis of hepatic dysfunction following aortic dissection repair

目的 分析Stanford A型和B型主动脉夹层患者在深低温停循环（DHCA）下主动脉替换手术后肝功能不全（HD）发生的相关危险因素.方法 收集2006年1月至2008年6月在DHCA（鼻温降至18 ℃）下行主动脉替换术的主动脉夹层病例208例,其中男性156例,女性52例,平均年龄（45±11）岁.术前诊断主动脉夹层Stanford A型181例,Stanford B型27例.记录患者的年龄、性别、术前合并症、术前心功能、主动脉夹层类型、手术类型、主动脉手术史、心肺转流时间、术中及术后24 h内的浓缩红细胞输入量.监测术前及术后1周内血谷丙转氨酶（GPT）、总胆红素及乳酸脱氢酶的水平.对术后HD发生的相关危险因素进行单因素分析及多因素Logistic回归分析.结果 该组病例术后早期（＜7 d）出现HD 18例（8.7%）.术前血肌酐＞133 μmol/L（P＜0.01）、术前GPT＞40 U/L（P＜0.01）、急性夹层（P＜0.05）、心肺转流时间＞180 min（P＜0.05）、阻断时间＞100 min（P＜0.05）、术中及术后24 h内输注浓缩红细胞＞10单位（P＜0.01）是HD发生的相关危险因素.其中术前GPT＞40 U/L（P＜0.01）和术中及术后24 h内输注浓缩红细胞＞10单位（P＜0.01）是其独立危险因素.结论 主动脉夹层术后HD是多因素导致的并发症.术前GPT升高及术中、术后早期的大量输血是影响术后HD发生的主要原因.

Objective To analyze the risk factors of hepatic dysfunction following Stanford A and Stanford B aortic dissection repair with deep hypothermic circulatory arrest （ DHCA）. Methods Between January 2006 and June 2008, 208 patients [156 male and 52 female, mean aged （45 ± 11） years] underwent open repairs of aortic dissection with DHCA. Indications for surgical intervention were type A aortic dissection in 181 patients and type B in 27 patients. Acute aortic dissection occurred on 121 patients, chronic aortic dissection occurred on 87 patients. Complications included hypertension, diabetes, cardiac dysfunction, renal dysfunction, and hepatic dysfunction. Twenty-one patients had previous aortic surgery. Data were gathered for multiple preoperative and intraoperative factors including age, gender, diagnosis, aortic dissection type, preoperative ejection fraction, aortic surgery history, surgical intervention type, cardiopulmonary bypass （ CPB ） time, aortic cross-clamp time, blood transfusion volume （ PRBC ） . Serum glutamic-pyruvic transaminase （GPT）, 1-lactate dehydrogenase （LDH） and total bilirubin （TBIL） were assayed before and after operation, as well as 12 h, ld,3d,5d,7d. These valuables were recorded and described statistically. All the factors were evaluated by means of univariate and multivariate Logistic analysis to identify relative risk factors of hepatic dysfunction. Results The CPB time and aortic cross-clamp time were （189 ±48） min and （93 ±41） min, respectively. Hepatic dysfunction occurred in 18 （8.7% ） patients. Serum GPT and serum LDH elevated significantly within 24 h after aortic surgery, and then went down gradually. Postoperative serum TBIL were much higher than preoperative level on the first day and there was no significant reduction during the following seven days. Preoperative serum creatinine 〉 133 μmol/L （P 〈 0. 01） , preoperative GPT 〉 40 U/L （P 〈 0. 01） , acute aortic dissection （P 〈 0.05 ） , CPB time 〉 180 min （P 〈0. 05） , aortic cross-clamp time 〉 100 min （P =0. 035）, PRBC 〉 10 unit （P 〈0. 01） were the risk factors for hepatic dysfunction. Furthermore preoperative GPT 〉40 U/L （P 〈0. 01） and PRBC 〉 10 unit （ P 〈 0. 01） were independent determinants for hepatic dysfunction. Conclusions Multiple risk factors impact the onset of postoperative hepatic dysfunction. Rather, a combination offactors, especially preoperative hepatic injury, massive blood transfusion produced the highest odds of deficit.