肥厚型梗阻性心肌病改良扩大Morrow术后新发心房颤动的危险因素分析及术前肾小球滤过率的预测价值

Risk factors and predictive value of estimated glomerular filtration rate for new-onset atrial fibrillation in patients with hypertrophic obstructive cardiom yopathy after modified extended Morrow procedure

目的探讨术前及围术期指标尤其是估算肾小球滤过率(eGFR)与肥厚型梗阻性心肌病(HOCM)患者改良扩大Morrow术后新发心房颤动(POAF)的相关性,并进一步寻找危险因素。方法回顾性分析我院2012年1月至2018年3月300例行单纯改良扩大Morrow术治疗的HOCM患者的临床资料,其中男197例(65.67%)、女103例(34.33%),平均年龄(43.54±13.81)岁。住院期间连续监测心律变化,根据是否发生POAF将患者分为POAF组(n=68)和非POAF组(n=232)。通过查阅病历收集一般资料、围术期参数及超声心动图结果进行统计分析。POAF的危险因素分析采用单因素及多因素logistic回归模型分析。结果住院期间POAF发生68例,发生率为22.67%。与非POAF患者比较,POAF患者年龄更大、胸痛和晕厥症状更多见、术前eGFR水平更低、体重指数和心功能分级(NYHA)更高,术前左心房内径、左心室舒张末期内径更大,呼吸机使用时间、住ICU时间和术后住院时间更长。多因素回归分析表明:年龄、心功能分级(NYHA)≥Ⅲ级、高血压、晕厥史、eGFR是POAF的独立危险因素。受试者工作特征曲线分析表明术前eGFR的曲线下面积为0.731(95%CI 0.677~0.780,P<0.001),敏感度和特异度分别为82.4%和57.8%。结论年龄增大、术前心功能分级高、高血压、术前晕厥史、eGFR下降是HOCM患者外科术后POAF的独立危险因素。术前eGFR下降可以中等程度预测HOCM患者单纯改良扩大Morrow术POAF的发生。

Objective To explore the association between preoperative, perioperative parameters, especially estimated glomerular filtration rate(eGFR) and postoperative atrial fibrillation(POAF) after modified extended Morrow procedure. Methods A total of 300 hypertrophic obstructive cardiomyopathy(HOCM) patients who underwent modified extended Morrow procedure in our hospital from January 2012 to March 2018 were collected. There were 197(65.67%)males and 103(34.33%) females with an average age of 43.54±13.81 years. Heart rhythm was continuously monitored during hospitalization. The patients were divided into a POAF group(n=68) and a non-POAF group(n=232). The general data, perioperative parameters and echocardiographic results were collected by consulting medical records for statistical analysis. Univariate and multivariate logistic regression models were used to analyze the risk factors for POAF.Results Overall incidence of POAF during hospitalization was 22.67%(68/300). Compared with patients without POAF,patients with POAF were older, had higher incidence of chest pain and syncope, lower level of preoperative eGFR, higher body mass index and heart function classification(NYHA), larger preoperative left atrial diameter and left ventricular end diastolic diameter, and longer ventilator-assisted time, ICU stay and postoperative hospital stay. Age, heart function classification(NYHA)≥Ⅲ, hypertension, syncope history and eGFR were independent risk factors for POAF. Receiver operating characteristic curve analysis showed that the area under the curve of eGFR was 0.731(95%CI 0.677-0.780,P<0.001), and the sensitivity and specificity were 82.4% and 57.8%, respectively. Conclusion Increased age, high preoperative heart function classification(NYHA), hypertension, preoperative syncope history and decreased eGFR are independent risk factors for POAF in HOCM patients who underwent surgical septal myectomy. Preoperative decreased eGFR can moderately predict the occurrence of POAF after modified extended Morrow procedure.