心脏瓣膜置换术合并冠脉搭桥术的危险因素分析

Analysis of risk factors of heart valve replacement combined with coronary artery bypass grafting

目的分析影响心脏瓣膜置换术（HVR）合并冠脉搭桥术（CABG）患者预后的危险因素。方法HVR合并CABG患者86例，分析患者术后近、中期的存活率、死亡率及并发症发生情况，比较术前、术后1周及术后3个月的心功能指标，包括左心房内径（LAD）、左心室舒张末径（LVEDD）、左心室射血分数（LVEF）、肺动脉压（PAP）；对影响患者预后的相关因素进行Logistic单因素及多因素回归分析。结果院内病死率为4．65％（4／86），其中多器官衰竭2例，室颤1例，低心排综合征1例；除死亡患者外，存活率为95．35％（82／86），术后3个月随访82例患者，随访率为95．35％，平均随访时间（2．60±0．30）个月；严重并发症发生率为5．81％（5／86）；随访期间，无死亡患者，患者术后心功能改善，术后1周和术后3个月患者的LAD、LVEDD及PAP与术前比较，均有明显改善（P〈0．05），而术后LVEF值与术前比较有所下降，但差异无统计学意义。Logistic单因素回归分析表明，年龄、心功能、瓣膜脓肿、移植血管桥数量、术后低心排、营养状态及LVEF是影响患者预后的危险因素；Logistic多因素回归分析显示，高龄、心功能NYHA分级（m或Ⅳ级）、移植血管桥数量及术后低心排是影响患者预后的独立危险因素。结论HVR合并CABG疗效确切，可改善患者的心功能；术后近、中期影响患者预后的危险因素具有多样性，高龄、心功能NYHA分级（Ⅲ或Ⅳ级）、移植血管桥数量、术后低心排及肺动脉高压是术后死亡或严重并发症发生的独立危险因素。

Objective To analyze the risk factors for prognosis in patients with cardiac valve re- placement（HVR） combined with coronary artery bypass grafting（CABG）. Methods A total of 86 pa- tients with CABG and HVR were enrolled;the short and medium term survivals, mortality and complica- tions ,and the comparison of cardiac function indicators including left atrial diameter（LAD） ,left ventricu- lar end-diastolic diameter（LVEDD） ,left ventricular ejection fractiot~ （LVEF）, pulmonary artery pressure （PAP） were analyzed before the surgery, on the I st week and 3rd month after surgery. Relevant factors of prognosis were analyzed by the univariate and multivariate Logistic regression Methods. Results The hos- pital mortality rate was 4.65 % （4/86）. Among them, there were two cases with multiple organ failure, one case with ventricular fibrillation, and one case with low cardiac output syndrome. In addition to mortality, the survival rate was 95.35% （ 82/86 ）. A total of 82 patients were followed up for 3 months. The follow-up rate was 95.35% with an average follow-up time of（2.60 ±0. 30 ） months ; the severe complication rate was 5.81% （5/86） ; during the follow-up, no deaths occurred, and compared with preoperative heart func- tion, postoperative heart function was significantly improved. At the 1st week and 3rd month after opera- tion,the value of LAD,LVEDD and PAP was significantly improved comparing with those before surgery （P 〈 0.05 ）. However, postoperative LVEF value was decreased and had no difference with that before surgery. The results of univariate logistic regression analysis showed that age, cardiac function, valvular ab- scesses ,the number of grafts, postoperative low cardiac output, nutritional status and LVEF were risk fac- tors for prognosis. The multivariate logistic regression analysis shown that age, NYHA class Ⅲ or Ⅳ grade ,low number of grafts and postoperative low cardiac output were independent risk factors for progno- sis. Conclusion HVR combined with CABG has definite clinical effects and significantly improves cardi- ac function in patients. The risk factors of the short and medium prognosis for patients with HVR combined with CABG were varietal. Advanced age, NYHA class （Ⅲ or Ⅳ grade）, the number of grafts and postopera- tive pulmonary hypertension were independent risk factors for postoperative death or serious complications.