成人先天性心脏病并发肺动脉高压外科治疗术后不良事件和右房改善的危险因素

Risk factor for adverse events and the improvement of right atrial size in patients with congenital heart disease associated with pulmonary arterial hypertension

目的分析先天性心脏病(CHD)并发肺动脉高压(PAH)(CHD-PAH)患者手术后不良事件、右房大小改善的危险因素。方法收治79例CHD-PAH患者。初诊,右心导管检查和吸氧实验,确诊PAH、肺血管反应性,其中13例患者肺血管阻力(PVR)<10 Wood单位、体循环血流量(Qp)与肺循环血流量(Qs)的比值(Qp/Qs)≥1.5、血氧饱和度(Sa O2)≥95%,且心功能较好者直接行手术治疗,其余66例患者接受靶向药物治疗3个月后,复查右心导管进行评估手术。结果术后不良事件发生17例,其中肺高压危象11例,撤机困难需气管切开4例以及低心排综合征2例。53例患者术后右房恢复正常大小。有无不良事件组间比较结果显示:术前PVR≥10 Wood单位、Qp/Qs、Sa O2、肺动脉收缩压/主动脉收缩压(SPAP/SBP)>0.75、SPAP、肺动脉舒张压(DPAP)是术后不良事件的影响因素(均P<0.01),多因素Logistic回归分析结果显示Sa O2(OR=0.584,P=0.015)越高,不良事件发生率越低;术后右房大小改善是否满意组间单因素分析显示:PVR≥10 Wood单位、右房压(RAP)>8 mm Hg(1 mm Hg=0.133 k Pa)、血流分流方向是其影响因素(均P<0.05),多因素Logistic回归分析结果显示其危险因素是RAP>8 mm Hg(OR=3.398,P=0.029)。结论 CHD-PAH患者术后不良事件的危险因素是Sa O2的降低,影响右房改善的危险因素是RAP>8 mm Hg。

AIM To analyze the risk factors of adverse events and the improvement of right atrial size before and after surgery in patients with congenital heart disease with pulmonary arterial hypertension （CHD-PAH）. METHODS From June 2014 to June 2016, 79 patients with CHD-PAH underwent surgical repair. There were 25 males and 54 females, 18 to 61 years old. Newly diagnosed, to having a diagnosis PAH and oxygen reactive pulmonary vasculature by right heart catheterization, 13 patients with pulmonary vascular resistance （PVR） 〈 10 Wood units, Qp/Qs~〉l. 5, Sa02 〉195% underwent direct surgical repair, who have better cardiac function. The remaining 66 patients received targeted therapy three months, then had an additional right heart catheterization. RESULTS The early postoperative adverse events included pulmonary crisis in 11 patients, tracheotomy with difficulty in extubation in 4 patients, low cardiac outputsyndrome occured in 2 patients; and there were 53 patients with postoperative right atrium returned to normal size. The preoperative PVR〉~10 Wood units, Qp/Qs, SaO2, systolic pulmonary arterial pressure/ systolic blood pressure （SPAP/SBP） 〉0. 75, SPAP, DPAP （ P 〈 0. 01 ） were influencing factors in the early postoperative adverse events. Univariate analysis revealed that the higher the SaO2 （ OR = 0. 584, P =0. 015） , the lower the incidence of adverse events. Preoperative PVR~ 10 Wood units, fight atrial pressure （RAP） 〉 8 mmHg, shunting direction （P 〈 0. 05 ） were the significantly impacted right atrial enlargement. Univariate analysis revealed RAP 〉 8 mmHg （ OR = 3. 398, P = 0. 029） was the independent risk factors of right atrial improvement. CONCLUSION The risk factor for postoperative adverse events in CHD-PAH patients was reduction of SaO~, and risk factor for fight atrial improvement was RAP 〉 8 mmHg.