成人瓣膜性心脏病围手术期高胆红素血症的危险因素分析

Risk factors for perioperative hyperbilirubinemia in adults with heart valve diseases

目的:研究成人瓣膜性心脏病(HVD)围手术期高胆红素血症(HB)的危险因素及并发症,探讨HB的管理策略。方法:回顾性分析2014年2月—2019年1月川北医学院附属医院心脏大血管外科727例HVD患者的临床资料,其中男334例,女393例。所有患者均在体外循环(CPB)下行手术治疗。记录患者围手术期的资料和血清总胆红素(TBIL)峰值,根据围手术期TBIL水平,将患者分为HB组(TBIL>34.2μmol/L,233例)和非HB组(TBIL≤34.2μmol/L,494例),比较两组患者术前、术中相关指标、术后并发症及围手术期病死率发生情况。将单因素分析中具有统计学意义的变量纳入多因素Logistic回归分析,进一步明确HB的危险因素。结果:成人HVD围手术期HB发生率约为32.1%。多因素分析结果显示,术前TBIL≥17.1μmol/L(OR=3.674,95%CI:1.943~4.791,P=0.011)、主动脉阻断时间≥90 min(OR=2.041,95%CI:0.961~6.361,P=0.009)、三尖瓣重度关闭不全(OR=1.973,95%CI:1.338~2.914,P=0.019)、24 h内输红细胞悬液≥1000 mL(OR=1.738,95%CI:1.558~6.364,P=0.027)、感染性心内膜炎(OR=3.590,95%CI:1.467~8.785,P=0.015)是成人HVD围手术期HB的独立危险因素。与非HB组比较,HB组术后引流量增多[(453.19±327.83)mL∶(518.74±389.19)mL,P=0.018]、急性肝衰竭(1.0%∶3.0%,P=0.048)、急性肾衰竭(10.3%∶18.5%,P=0.002)、急性肺损伤(6.7%∶11.1%,P=0.039)、肺部感染(8.3%∶13.3%,P=0.035)、低心排综合征(7.1%∶12.4%,P=0.017)发生率明显增高,机械通气时间[(23.96±29.29)h∶(37.14±44.85)h,P<0.001]、ICU停留时间[(2.43±2.58)d∶(3.84±4.09)d,P<0.001]及住院时间[(14.89±3.16)d∶(16.31±4.47)d,P<0.001]均明显延长,围手术期病死率(2.8%∶6.4%,P=0.021)明显增加。结论:成人HVD术后HB发生率较高,术前TBIL≥17.1μmol/L、主动脉阻断时间≥90 min、三尖瓣重度关闭不全、24 h内输红细胞悬液≥1000 mL、感染性心内膜炎是成人HVD围手术期HB的独立危险因素。HB与围手术期并发症发生率、病死率、住院时间延长显著相关。

Objective:To analyze the risk factors and complications of perioperative hyperbilirubinemia(HB)in adults with heart valve diseases(HVD),and to investigate the management strategy of HB.Methods:A total of 727 patients including 334 males and 393 females with HVD from February 2014 to January 2019 admitted in the Department of Cardiovascular Surgery,Affiliated Hospital of North Sichuan Medical College were retrospectively analyzed.All patients underwent operation by cardiopulmonary bypass(CPB)with general anesthesia.The perioperative data and total bilirubin(TBIL)were recorded.According to the level of perioperative TBIL,patients were divided into HB group(TBIL>34.2μmol/L,n=233)and non-HB group(TBIL≤34.2μmol/L,n=494).The preoperative and intraoperative indexes,postoperative complications and perioperative mortality between the two groups were compared.The variables with statistical significance in univariate analysis were included into multivariate Logistic regression analysis to further clarify the risk factors of HB.Results:The incidence of perioperative HB in aldults with HVD was about 32.1%.Multivariate Logistic regression analysis showed that preoperative TBIL≥17.1μmol/L(OR=3.674,95%CI:1.943-4.791,P=0.011),aortic occlusion time≥90 min(OR=2.041,95%CI:0.961-6.361,P=0.009),severe tricuspid insufficiency(OR=1.973,95%CI:1.338-2.914,P=0.019),input of red blood cell in 24 h≥1000 mL(OR=1.738,95%CI:1.558-6.364,P=0.027),infective endocarditis(OR=3.590,95%CI:1.467-8.785,P=0.015)were independent risk factors for perioperative HB.Compared with the non-HB group,the postoperative drainage volume significantly increased in the HB group[(453.19±327.83)mL∶(518.74±389.19)mL,P=0.018],the incidence of acute liver failure(1.0%∶3.0%,P=0.048),acute renal failure(10.3%∶18.5%,P=0.002),acute lung injury(6.7%∶11.1%,P=0.039),pulmonary infection(8.3%∶13.3%,P=0.035),low cardiac output syndrome(7.1%∶12.4%,P=0.017)were significantly increased,the duration of mechanical ventilation[(23.96±29.29)h∶(37.14±44.85)h,P<0.001]and ICU stay time[(2.43±2.58)d∶(3.84±4.09)d,P<0.001]and hospitalization time[(14.89±3.16)d∶(16.31±4.47)d,P<0.001]were significantly prolonged,and the perioperative mortality(2.8%∶6.4%,P=0.021)was significantly increased.Conclusion:The preoperative TBIL≥17.1μmol/L,aortic occlusion time≥90 min,severe tricuspid insufficiency,the input of red blood cell in 24 h≥1000 mL,and infective endocarditis are independent risk factors for postoperative HB in adults with HVD.HB is significantly correlated with the incidence of perioperative complications,mortality and length of hospital stay.