术前脑血管评估对非体外循环冠状动脉旁路移植术后神经系统并发症的影响研究

Influence of Preoperative Cerebrovascular Evaluation on Neurological Complications Following Off-Pump Coronary Artery Bypass Grafting

目的探讨非体外循环冠状动脉旁路移植术(OPCABG)后神经系统并发症(NC)的发生率及其危险因素,并明确术前脑灌注异常、颅脑CT血管成像(CTA)狭窄情况与术后NC的关系。方法选取2010年7月—2012年7月北京安贞医院心脏外科连续收治的具有行OPCABG手术指征患者556例,术前均采用320排动态容积CT评估脑灌注情况,采用颅脑CTA评估脑血管狭窄情况。所有患者分别于术前和术后1周进行NC评估,根据OPCABG后是否发生NC分为NC组(n=118)和非NC组(n=438),分析脑灌注异常、颅脑CTA狭窄情况对术后NC的影响。结果术后NC总发生率为21.2%(118/556),其中脑梗死为1.3%(7/556),缺血低氧性脑病(HIE)为2.9%(16/556),谵妄为1.1%(6/556),术后认知功能障碍(POCD)为11.9%(66/556),焦虑、抑郁状态为6.0%(33/556)。NC组脑血管病史、脑灌注异常比例及颅脑CTA狭窄程度均高于非NC组,差异有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,脑血管病史、术前脑灌注异常为术后NC发生的独立影响因素(P<0.05)。多因素Logistic回归分析结果亦显示,与颅脑CTA无狭窄患者相比,重度狭窄患者术后发生NC的OR(95%CI)为2.25(1.35,3.77),P<0.05。NC组颞叶、枕叶、基底核区达峰时间(TTP)差值,枕叶、基底核区对比剂平均通过时间(MTT)差值均大于非NC组,差异有统计学意义(P<0.05)。结论 OPCABG后NC发生率较高,脑血管病史、术前脑灌注异常为术后NC的独立危险因素,随着颅脑CTA狭窄程度增加,术后NC的发生风险逐渐增加。

Objective To investigate the incidence and risk factors of neurological complications（ NC） following off-pump coronary artery bypass grafting（ OPCABG）.Methods We recruited 556 patients who were admitted into Department of Cardiac Surgery of Beijing Anzhen University and underwent OPCABG there from July 2010 to July 2012.Before surgery, the subjects all received 320- row dynamic volume CT to evaluate cerebral perfusion,and cerebral CTA was used to evaluate the condition of cerebrovascular stenosis.All patients received NC evaluation before surgery and one week after surgery.According to whether NC occurs after OPCABG,the subjects were divided into two groups： NC group（ n = 118） and non- NC group（ n= 438）.The influence of abnormality of cerebral perfusion and the condition of stenosis evaluated by CTA on postoperative NC was analyzed.Results The total incidence of NC was 21.2%（ 118 /556）, and among the NC events, cerebral infarction,hypoxic- ischemic encephalopathy, delirium, postoperative cognitive dysfunction and anxiety and depression accounted for1.3%（ 7 /556）,2.9%（ 16 /556）,1.1%（ 6 /556）,11.9%（ 66 /556） and 6.0%（ 33 /556）.The NC group was higher than non- NC group in the proportion of patients with history of cerebrovascular disease, proportion of cerebral perfusion abnormity and the degree of coronary artery stenosis evaluated by CTA（ P〈0.05）.Multivariate logistic regression analysis showed that history of cerebrovascular disease and preoperative abnormality of cerebral perfusion were independent influencing factors for the occurrence of NC after surgery（ P〈0.05）.Multivariate logistic regression showed that,compared with patients with no stenosis detected by CTA,the OR（ 95% CI） of NC in patients with serious stenosis after surgery was 2.25（ 1.35,3.77）,P〈0.05.Difference values among temporal lobe,occipital lobe and basal ganglia region in time to peak（ TTP） and the difference value between occipital lobe and basal ganglia region in mean transit time（ MTT） of contrast agent were significantly higher in the NC group than those in non- NC group（ P〈0.05）.Conclusion The incidence of NC is high after OPCABG,and the history of cerebrovascular disease and the preoperative cerebral perfusion abnormality are independent risk factors for postoperative NC.With the increase of stenosis detected by cerebral CTA,the incident of postoperative NC increases