急性A型主动脉夹层伴灌注不良综合征术后死亡危险因素分析

Risk factors of postoperative death in patients with acute type A aortic dissection with malperfusion syn⁃drome

目的分析急性A型主动脉夹层(acute type A aortic dissection,AAAD)伴灌注不良综合征(malperfusion syndrome,MPS)患者术后死亡的危险因素,为更合理制定临床治疗策略提供参考。方法回顾性分析2006年8月至2018年9月期间海军军医大学附属广州临床医学院连续手术的299例AAAD患者的临床资料,诊断合并MPS110例,其中术后死亡28例,纳入死亡组,82例存活患者纳入存活组。比较死亡组及存活组患者的围术期资料,将单因素分析有统计学意义的结果(P<0.05)纳入多因素Logistic回归,明确术后死亡独立危险因素,并采用受试者工作特征(receiver operating characteristic,ROC)曲线对所得危险因素的预测效能进行判断。结果单因素分析可得两组间患者的术前肌酐浓度、动脉血氧分压、急诊手术、肾脏灌注不良、2个以上脏器灌注不良、体外循环时间、主动脉阻闭时间、低流量脑灌注时间、脓毒症、连续肾脏替代治疗、恶性心律失常发生率比较,差异有统计学意义(均P<0.05)。将单因素比较有统计学意义的指标纳入二项分类Logistic回归分析,得出:2个以上脏器灌注不良、体外循环时间>240 min、主动脉阻闭时间>120 min和急诊手术是AAAD伴MPS患者术后死亡的独立危险因素。ROC曲线分析结果显示,联合预测概率的曲线下面积为0.896,有统计学意义(P<0.01),预测敏感性为92.9%,特异性为51.2%。结论AAAD患者术前伴MPS危害大,手术死亡率高。2个以上脏器灌注不良、体外循环时间>240 min、主动脉阻闭时间>120 min、急诊手术是AAAD伴MPS患者术后死亡的独立危险因素。

Objectives To analyze the risk factors of postoperative death in patients with acute type A aortic dissection(AAAD)complicated with malperfusion syndrome(MPS),so as to provide a reference for more reasonable develop⁃ment of clinical treatment strategies.Methods A retrospective analysis was performed on 299 patients with AAAD who underwent surgery from August 2006 to September 2018 in Guangzhou Clinical Medicine College of Naval Medical University.Of them,110 patients were diagnosed with MPS,among which 28 patients died after surgery.The perioperative data of the patients who died and survived were compared,and the statistically significant results of univariate analysis were included in multivariate Logistic regression to identify the independent risk factors for postoperative death,and the predictive efficacy of the obtained risk factors was judged by the receiver operating characteristic(ROC)curve.Results Univariate analysis identified that the differences between the two groups in preoperative serum concentration of creatinine,arterial partial pressure of oxygen,emergency operation,renal malperfusion,multi-organs malperfusion,extracorporeal circulation duration,aortic occlusion duration,low-flow cerebral perfusion duration,sepsis,continuous renal replacement therapy and malignant arrhythmia were statistical significant(P<0.05).All of them were included in binomial Logistic regression analysis,and the following results were obtained:multi-organs malperfusion,extracorporeal circulation duration>240 min,aortic occlusion duration>120 min and emergency surgery were independent risk factors for postoperative death in patients with AAAD complicated with MPS.The area under the curves(AUC)of Logistic regression joint detection was 0.896,which showed significant differences(P<0.01).The sensitivity of Logistic regres⁃sion joint detection was 92.9%and the specificity was 51.2%.Conclusions Patients with AAAD complicated with MPS is of great harm,which seriously increases the surgical mortality.Multi-organs malperfusion,emergency operation,extracorp oreal circulation duration>240 min,aortic occlusion duration>120 min are independent risk factors of postoperative death in patients with AAAD complicated with MPS.