伴卒中史患者非体外循环冠状动脉旁路移植术后再发急性脑梗死的影响因素分析

Influencing factors analysis of acute recurrent cerebral infarction following off-pump coronary artery bypass grafting in patients with prior stroke

目的探讨伴有卒中史患者非体外循环冠状动脉旁路移植(OPCAB)术后再发急性脑梗死的相关因素。方法回顾性分析首都医科大学附属北京安贞医院2010年1月—2012年9月,468例有卒中史OPCAB手术患者的临床资料。根据术后有无再发急性脑梗死分为再发脑梗死组(A组)41例和无再发脑梗死组(B组)427例。分析与缺血事件发生的相关因素[术后再发脑梗死的时间为完成手术入住重症监护病房(ICU)期间]。结果 468例OPCAB手术患者术后再发急性脑梗死41例,占8.8%。①单因素分析显示,A、B组间术前双侧颈内动脉重度狭窄[(41.5%(17/41),8.9%(38/427)]、术前左心室射血分数≤35%[53.7%(22/41),25.8%(110/427)]、术中En-closeⅡ主动脉近端吻合器的应用[19.5%(8/41),76.3%(326/427)]、术后急性心肌梗死[34.1%(14/41),9.1%(39/427)]、术后心房颤动[48.8%(20/41),10.8%(46/427)]、术后低血压[68.3%(28/41),18.7%(80/427)]、术后机械通气时间>72 h[(75.6%(31/41),15.0%(64/427)]、入住ICU时间>72 h[(82.9%(34/41),25.3%(108/427)]及病死率[(29.3%(12/41),5.4%(23/427)],差异均有统计学意义(均P<0.01)。②多因素Logistic回归分析显示,术前双侧颈内动脉重度狭窄(OR=6.338,95%CI:2.283～21.019)、术前左心室射血分数≤35%(OR=2.737,95%CI:1.267～6.389)、术后急性心肌梗死(OR=3.656,95%CI:1.933～6.894)、术后心房颤动(OR=3.104,95%CI:1.135～8.016)与术后低血压(OR=4.173,95%CI:1.836～9.701)是OPCAB患者术后再发急性脑梗死的独立危险因素。术中应用EncloseⅡ主动脉近端吻合器(OR=0.556,95%CI:0.337～0.925)是OPCAB患者术后再发急性脑梗死的保护因素。结论伴有卒中史患者行OPCAB术后,再发急性脑梗死的发生率及病死率高,术前双侧颈内动脉重度狭窄、术前左心室射血分数≤35%、术后急性心肌梗死、术后心房颤动和术后低血压是伴有卒中史患者OPCAB术后再发急性脑梗死的独立危险因素。而术中应用EncloseⅡ主动脉近端吻合器是伴有卒中史患者OPCAB术后再发急性脑梗死的保护因素。

Objective To investigate the related factors of acute recurrent cerebral infarction following off-pump coronary artery bypass grafting（OPCAB） in patients with prior stroke.Methods The clinical data of 468 patients with prior stroke who underwent OPCAB in Beijing Anzhen Hospital,Capital Medical University from January 2010 to September 2012 were analyzed retrospectively.The patients were divided into either a recurrent cerebral infarction group（group A,n=41） or a non-recurrent cerebral infarction group（group B,n=427） according to whether they had recurrent cerebral infarction or not after procedure.The related factors associated with the onset of ischemic events were analyzed（the time of recurrent cerebral infarction after procedure was during the time at the intensive care unit after completing the procedure）.Results Of the 468 patients underwent OPCAB,41（8.8%） with prior stroke before procedure had acute recurrent cerebral infarction after procedure.①Univariate analysis showed the preoperative bilateral internal carotid artery severe stenosis（41.5%,17/41 vs.8.9%,38/427）,preoperative left ventricular ejection fraction ≤ 35%（53.7%,22/41 vs.25.8%,110/427）,intraoperative application of aortic proximal anastomosis device（Enclose Ⅱ）（19.5%,8/41 vs.76.3%,326/427）,postoperative acute myocardial infarction（34.1%,14/41 vs.9.1%,39/427）,postoperative atrial fibrillation（48.8%,20/41 vs.10.8%,46/427）,postoperative hypotension（68.3%,28/41 vs.18.7%,80/427）,duration of mechanical ventilation 72 h（75.6%,31/41 vs.15.0%,64/427）,ICU stay 72 h（82.9%,34/41 vs.25.3%,108/427）,and mortality（29.3%,12/41 vs.5.4%,23/427） in both group A and B.There were significant differences between the two groups（all P0.05）.②Multivariate logistic regression analysis showed that the preoperative bilateral internal carotid artery severe stenosis（OR=6.338,95% CI： 2.283 to 21.019）,preoperative left ventricular ejection fraction ≤35%（OR=2.737,95% CI： 1.267 to 6.389）,postoperative acute myocardial infarction（OR=3.656,95% CI： 1.933 to 6.894）,postoperative atrial fibrillation（OR=3.104,95% CI： 1.135 to 8.016）,and postoperative hypotension（OR=4.173,95% CI： 1.836 to 9.707） were the independent risk factors for postoperative recurrent acute cerebral infarction in patients of OPCAB.Using Enclose Ⅱ proximal aortic anastomosis device during the procedure（OR=0.556,95% CI： 0.337 to 0.925） was the protective factor for postoperative acute recurrent cerebral infarction in patients of OPCAB.Conclusion The incidence and mortality of acute recurrent cerebral infarction are high following OPCAB in patients with prior stroke.Preoperative bilateral severe carotid artery stenosis,preoperative left ventricular ejection fraction ≤35%,postoperative acute myocardial infarction,postoperative atrial fibrillation and hypotension are the independent risk factors for acute recurrent cerebral infarction following OPCAB in patients with prior stroke,and using Enclose Ⅱ proximal aortic anastomosis device during the procedure is a protective factor for acute recurrent cerebral infarction following OPCAB in patients with prior stroke.