单中心130例再次心脏瓣膜手术病因及围术期风险因素分析

Causes and perioperative risks of 130 cardiac valve reoperations:a contemporary single-center analysis

目的回顾性分析复旦大学附属中山医院再次心脏瓣膜手术病例并探究病因及术后恢复的影响因素。方法分析2015年5月至2017年10月在复旦大学附属中山医院心外科施行再次心脏瓣膜手术患者130例,年龄15~83岁,其中男性62例(47.7%),女性68例(52.3%)。收集患者的临床资料,包括术前合并症、术前心功能、初次手术方式、两次手术间隔时间、再次手术原因及手术类型、主动脉阻断时间及体外循环时间、术后并发症、术后重症监护时间等。对再次瓣膜手术病例做Logistic回归,分析其严重并发症的影响因素。结果再次手术前合并高血压、糖尿病、肺动脉高压、房颤等疾病者114例(87.7%),术后死亡8例(6.2%),主要死亡原因包括心功能不全(7例)、呼吸功能不全(6例)和肾功能不全(6例)等。而再次手术的原因主要包括瓣膜赘生物、瓣周漏、三尖瓣关闭不全和大血管病变等;多因素Logistic回归分析结果显示,患者术前合并肺动脉高压(P=0.039,OR=2.268)和高血压病(P=0.048,OR=7.935)是导致患者术后死亡的危险因素;剔除35例术前心功能严重减低的病例后,多因素回归分析发现,术前合并肺动脉高压(P=0.040,OR=1.682)和风湿性心脏病(P=0.013,OR=4.995)与术后新发心功能不全显著相关,而单因素回归分析仅发现术前肾功能不全(P=0.048,OR=6.727)与术后新发呼吸功能不全显著相关,未行多因素分析。结论心、肺、肾功能异常是导致再次瓣膜手术风险升高的重要因素,着重评估术前的主要器官功能并予积极保护,对提高患者的预后十分重要。

Objective To explore risk factors retrospectively on the causes and adverse peri-operation effects of patients undergoing valve-associated repeated heart surgeries in 3 years recently.Methods Clinical data of 130 consecutive patients who underwent secondary heart valve surgeries from May 2015 to Oct 2017 in Zhongshan Hospital,Fudan University was retrospectively analyzed,containing 62 male patients and 68 female patients aging from 15 years old to 83 years old.The following data were collected:preoperative complications,preoperative heart function,initial operative types,the interval between two operations,the causes and types of the reoperation,the aorta block time and extracorporeal circulation time,postoperative complications,postoperative ICU time,etc.Multivariate logistic regression was used to analyze the risk factors of servere adverse postoperative complications,especially the death.Results A total of 114 cases(87.7%)were complicated with hypertension,diabetes,pulmonary artery hypertension,atrial fibrillation and other diseases before reoperation and 8 cases(6.2%)died postoperatively.The main causes of death included cardiac dysfunction(7 cases),respiratory dysfunction(6 cases),and renal dysfunction(6 cases).The main reasons for the reoperation of valvular diseases are valve vegetation,perivalvular leakage,tricuspid regurgitation and aorta lesions.Multivariate Logistic regression analysis showed that preoperative pulmonary hypertension(P=0.039,OR=2.268)and blood hypertension(P=0.048,OR=7.935)were the risk factors for the postoperative death.After excluding 35 cases with severe reduction in preoperative cardiac function,multivariate regression revealed that preoperative pulmonary hypertension(P=0.040,OR=1.682)and rheumatic heart disease(P=0.013,OR=4.995)had a significant correlation with new postoperative cardiac dysfunction,while univariate regression revealed a correlation between preoperative renal dysfunction(P=0.048,OR=6.727)and new postoperative respiratory dysfunction.Conclusion Abnormal cardiac,respiratory and renal functions are the important factors leading to increased risk of secondary operations of heart valve.It is very important to evaluate the function of major organs to protect the patients before reoperation.