倾向评分法评估Sutureless技术治疗完全性肺静脉异位引流的效果

Comparison between Two Surgical Techniques to Repair Total Anomalous Pulmonary Venous Connection Using propensity Scoreanalysis

【目的】以两种治疗先天性心脏病完全性肺静脉异位引流(TAPVC)不同的手术方法(Sutureless技术和传统方法)为例,应用倾向评分方法评估不同手术方法的优劣。【方法】连续入组2007年10月1日至2013年12月31日本中心所有行外科矫治术的TAPVC婴幼儿179名病例,其中Sutureless组81人,传统手术组98人。病人随访时间为术后1、3、6、12个月。采用三种倾向评分方法(最邻近卡钳法、马氏距离法、成对最佳法)匹配基线因素,匹配变量为:术前肺静脉狭窄(PrePVO)、年龄、性别、体质量、是否新生儿、TAPVC类型。以随机效应脆弱风险模型验证多水平效应,用Kaplan-Meier生存分析与多因素Cox分析方法比较两组手术指标及术后生存率差异。【结果】使用倾向评分中的最邻近卡钳法匹配效果最好。匹配后,Sutureless组中位数体外循环时间87(74.5~103.0)min少于传统手术组99(76.5~123.5)min(P=0.030);Sutureless组中位数主动脉阻断时间43(35~54.5)min少于传统手术组55(40.5~705)min(P<0.001);复合事件发生率Sutureless组6.8%(5/73)显著低于传统手术组24.7%(18/73),HR的95%CI=0.20(0.06~0.61),P=0.005。院外死亡发生率Sutureless组1.4%(1/73)低于传统手术组6.8%(5/73),HR的95%CI=0.03(0.01~0.55),P=0.017。两组在术后肺静脉梗阻、围术期死亡率无统计学差异。【结论】使用倾向评分方法评估先天性TAPVC的不同治疗方法的效果显示,使用Sutureless技术能缩短患者术中的主动脉阻断时间与体外循环时间,能降低术后复合事件的发生率及院外死亡率。

【Objective】To evaluate the effects of sutureless technique in comparison to conventional techniques for repair of total anomalous pulmonary venous connection（TAPVC）with the method of propensity score analysis.【Methods】From October 2007 to December 2013,179 consecutive patients were enrolled in this study. Patients were operated with sutureless technique（n = 81）or Conventional technique（n = 98）,and followed up at an interval of 1 month,3 months,6 months and then once a year post-operation.During analysis,three type of propensity-score matching methods,including nearest neighbor caliper matching,Mahalanobis metric matching with propensity score,optimal full matching were used to create balanced groups of patients receiving each treatment.Surgeons＇ performance difference was assessed with random frailty proportional hazards models with gamma. Composite endpoints was defined by postoperative death or late death or postoperative pulmonary venous obstruction（PVO）,which was evaluated with KaplanMeier curve and multivariable Cox proportional hazard model,adjusted by Preoperative-PVO,age,gender,weight and TAPVC type.【Results】Nearest neighbor caliper matching method was the best choice during propensity score analysis. After matching,sutureless group included 73 patients and Conventional group73 patients. In sutureless group,cardiopulmonary bypass（CPB）time（Z = 2.18,P = 0.030）,cross-clamp time（Z = 3.63,P〈 0.001）,rate of composite endpoints（HR 95% CI= 0.20（0.06-0.61）,P = 0.005）,late death（HR 95% CI=0.03（0.01-0.55）,P = 0.017）were significantly better than that in Conventional group. In subgroup analysis,for patients with pre-PVO,decreased composite endpoints was seen in sutureless group.【Conclusion】Comparison using thepropensity score analysis demonstrated that sutureless strategy for primary repair of TAPVC may associate with decreased mortality rate of postPVO and CPB time and cross-clamp time.