小儿法洛四联症围术期不良预后相关风险因素分析及评估

Analysis and evaluation of risk factors associated with poor prognoses of children with tetralogy of Fallot during perioperative period

目的探讨小儿法洛四联症围术期不良预后的相关风险因素,并建立风险评估模型评价其临床应用价值。方法回顾性分析广东省人民医院2016年9月至2019年1月行法洛四联症一期矫治术119例患儿的临床资料,其中男75例、女44例,年龄(13.2±1.4)个月,体重(8.3±0.2) kg。119例临床资料被分为不良预后组(n=47)和正常预后组(n=72)。使用单因素和多因素logistic分析风险因素与不良预后之间的关联。结果全组1例围术期死亡,出现主要不良事件共9例。LASSO回归筛选与不良预后相关变量包括2个术前变量(McGoon指数,主动脉根部直径指数),4个术中变量(肺动脉二叶瓣左右方向、右室流出道切口总长度指数、交界切开处理肺瓣、体外循环最低体温)。使用单因素和多因素logistic分析分别纳入上述因素,其中同时差异有统计学意义(P≤0.05)的变量有McGoon指数、主动脉根部直径指数、肺动脉二叶瓣左右方向、体外循环最低体温。列线图结果显示肺动脉二叶瓣左右方向比三叶瓣和二叶瓣前后方向发生不良预后的风险概率更高;McGoon指数越小,主动脉根部直径越大以及术中体外循环体温越低,法洛四联症患儿发生不良预后事件的风险概率越高。结论肺动脉二叶瓣左右方向比三叶瓣和二叶瓣前后方向的不良预后风险更高;McGoon指数越小及主动脉根部直径越大,预后不良发生的风险越高;术中体外循环中体温若低于27℃与不良预后事件的高发生率明显相关,可作为今后小儿法洛四联症术中决策的辅助参考标准。

Objective To quest the risk factors of poor prognoses in children with tetralogy of Fallot(TOF)during perioperative period and evaluate its clinical application values.Methods A retrospective analysis of the clinical data of 119 children who underwent one-stage correction of TOF in Guangdong Provincial People’s Hospital fromSeptember 2016 to January 2019.The cohort includes 75 males and 44 females,with ages ranging from 3.2-137.1(13.2±1.4)months and weights ranging from 4.6-21.0(8.3±0.2)kg.Perioperative poor prognosis was defined as duration of mechanically assisted ventilation>48 h or secondary intubation,vasoactive-inotropic score(VIS)within 48 h>40,postoperative length of stay>14 d,and the occurrence of the major adverse events.Major adverse events were defined as early death,malignant arrhythmia,low cardiac output syndrome,non-fatal cardiac arrest,postoperative reintervention,diaphragm paralysis,and other clinical complications.Univariate and multivariate logistic analyses were used to analyze the correlation between risk factors and poor prognoses.Results There was 1 perioperative death,and 9 with major adverse events.Variables selected by Least Absolute Shrinkage and Selection Operator(LASSO)included 2 preoperative variables(Mc Goon index,aortic root diameter index)and 4 intra-operative variables[left-right direction of bicuspid pulmonary valve,total length of right ventricular outflow tract(RVOT)incision index,pulmonary valve with commissurotomy,and minimum temperature in cardiopulmonary bypass(CPB)].Univariate and multivariate logistic analyses were used to the above factors,respectively.The variables with statistical significance(P≤0.05)were Mc Goon index,aortic root diameter index,left-right direction of bicuspid pulmonary valve,and minimum temperature in CPB.A nomogram was established based on the above factors,and the results showed that the left-right direction of bicuspid pulmonary valve was more risky than the tricuspid pulmonary valve and the anterior-posterior direction of bicuspid pulmonary valve.The lower the Mc Goon index,the higher aortic root diameter,and the lower temperature in CPB,the higher risk of poor prognostic events in children with TOF.Conclusion The left-right direction of the pulmonary bicuspid valve has a higher risk of poor prognosis than the tricuspid pulmonary valve and the anterior-posterior direction of bicuspid pulmonary valve.With the smaller Mc Goon index and the larger aortic root diameter,the risk of poor prognoses in children with TOF is higher.The temperature in CPB being lower than medium-low temperature obviously relates to the high incidence of poor prognostic events,which can be used as an auxiliary reference standard for decisionmaking in pediatric TOF surgery in the future.