同期左心耳闭合预防二尖瓣置换术后缺血性脑卒中的早期结果

Early results of left atrial appendage closure in cerebral ischemic stroke reduction in patients with mitral valve replacement

目的 探讨同期闭合左心耳预防二尖瓣置换术后缺血性脑卒中的作用.方法 回顾性分析2008年1月至2013年1月住院的860例接受二尖瓣置换的成年患者临床资料,其中男性414例,女性446例,平均年龄（53±12）岁.按术中是否同期闭合左心耳分为闭合组（n=521）和非闭合组（n =339）,比较分析术后住院期间缺血性脑卒中发生情况,采用Logistic逐步回归分析法分析缺血性脑卒中危险因素,探讨左心耳闭合对瓣膜置换术后缺血性脑卒中的影响.结果 闭合组女性比例较高,合并心功能不全、肺动脉高压和左心房血栓比例较高,术前左心房内径较大,植入机械瓣、同期处理三尖瓣比例较高,但合并高血压和接受冠状动脉旁路移植术比例较低,主动脉瓣阻断时间较短（χ^2 =6.807 ～122.576,t=-2.818、3.756,P值均＜0.05）.两组术后开胸止血和住院期间病死率差异无统计学意义（P＞0.05）.术后住院期间共12例患者缺血性脑卒中,发生率1.4％.闭合组缺血性脑卒中发生率低于非闭合组（0.6％比2.7％,χ^2 =6.452,P=0.011）.Logistic多因素回归分析结果显示,左心耳闭合是术后住院期间缺血性脑卒中的保护因子（OR=0.189,95％ CI：0.039 ～0.902,P=0.037）,术前脑血管病史（OR=4.326,95％ CI：1.074 ～ 17.418,P=0.039）和术前左心房内径（OR=1.059,95％ CI：1.022～1.098,P=0.002）是术后缺血性脑卒中的危险因素.对术前是否合并心房颤动的亚层分析显示,左心耳闭合是预防心房颤动患者术后缺血性脑卒中的强预测因素（OR=0.064,95％ CI：0.006 ～0.705,P=0.025）,而对于非心房颤动患者则并非预测因素（OR=1.902,95％ CI：0.171～21.191,P=0.601）.结论 二尖瓣置换术同期闭合左心耳操作安全,可以降低心房颤动患者二尖瓣置换术后早期缺血性脑卒中的发生率.

Objective To investigate the role of left atrial appendage （LAA） closure for cerebral ischemic stroke prevention following mitral valve replacement.Methods Retrospective data on 860 consecutive adult patients undergoing mitral valve replacement between January 2008 and January 2013 were analyzed.There were 414 male and 446 female patients,with a mean age of （53 ± 12） years.The patients were divided into two groups according to whether the left atrial appendage was closed during operation：LAA closure group （n =521） and non-LAA closure group （n =339）.Early mortality,postoperative cerebral ischemic stroke and the risk factors for cerebral ischemic stroke were assessed.Multivariate analysis was performed using logistic regression analysis.Results Compared with non-LAA closure group,LAA closure group had higher proportion of female gender,higher percentage of patients with cardiac insufficiency,pulmonary hypertension and left atrial thrombus,higher incidence of mechanical valve implantation and concurrent tricuspid surgery,and larger preoperative diameter of left atrium,but lower proportion of hypertension and patients undergoing coronary artery bypass surgery,and shorter aorta cross clamping time （χ^2 =6.807 to 122.576,t =-2.818 and 3.756,all P 〈0.05）.There were no differences in exploratory thoracotomy for bleeding and in-hospital mortality between the two groups.Postoperative cerebral ischemic stroke occurred in 12 patients （1.4%）.The incidence of cerebral ischemic stroke in LAA closure group was significantly lower than in non-LAA closure group （0.6% vs.2.7%,χ^2 =6.452,P =0.011）.Logistic regression analysis showed that LAA closure was a significant protective factor for postoperative cerebral ischemic stroke （OR =0.189,95% CI：O.039 to 0.902,P =0.037） while history of cerebrovascular disease （OR =4.326,95% CI：1.074 to 17.418,P =0.039） and preoperative diameter of left atrium （OR =1.509,95% CI：1.022 to 1.098,P =0.002） being the independent risk factors for postoperative cerebral ischemic stroke.The subgroup analysis showed that,for atrial fibrillation patients,LAA closure was a strong protective factor （OR =0.064,95% CI：0.006 to 0.705,P =0.025）,but LAA closure was not a significant predictive factor （OR =1.902,95% CI：0.171 to 21.191,P =0.601） in non-atrial fibrillation patients.Conclusion Concurrent LAA closure during mitral valve replacement is safe and effective to reduce the early postoperative risk of cerebral ischemic stroke in atrial fibrillation patients.