急性心肌梗死后并发室间隔穿孔患者行主动脉内球囊反搏治疗院内死亡的影响因素

Influencing factors of in-hospital death after intra-aortic balloon pump in patients with ventricular septal rupture secondary to acute myocardial infarction

目的 观察急性心肌梗死(acute myocardial infarction, AMI)后并发室间隔穿孔(ventricular septal rupture, VSR)患者行主动脉内球囊反搏(intra-aortic balloon pump, IABP)辅助治疗的效果,探讨其院内死亡的影响因素。方法94例AMI后并发VSR患者,均在常规药物治疗基础上行IABP辅助治疗,院内死亡56例为死亡组,存活38例为存活组。比较2组基础疾病、AMI发病至就诊时间、心肌梗死部位、急诊冠状动脉再灌注治疗比率、AMI后并发VSR时间、VSR直径、VSR部位等临床资料;记录2组入CCU后序贯器官衰竭(sequential organ failure assessment, SOFA)评分、白细胞计数、血乳酸、左室射血分数、左心室舒张末期内径等临床资料;比较2组IABP辅助治疗时间及体外膜肺氧合辅助、呼吸机辅助、连续肾脏替代治疗、行室间隔缺损封堵术比率等;多因素logistic回归分析行IABP辅助治疗AMI后并发VSR患者院内死亡的影响因素。结果 死亡组入CCU后SOFA评分[(11.5±3.8)分]、白细胞计数[(15.3±4.9)×10^(9)/L]、血乳酸[4.6(2.1,6.1)mmol/L]水平均高于存活组[(6.2±2.1)分、(12.5±4.5)×10^(9)/L、1.5(1.1,2.2) mmol/L](P<0.05),体外膜肺氧合辅助(17.9%)、呼吸机辅助(57.1%)、连续肾脏替代治疗(51.8%)比率均高于存活组(2.6%、21.6%、18.4%)(P<0.05),行室间隔缺损封堵术比率(25.0%)低于存活组(86.8%)(P<0.05);2组合并高血压、糖尿病、高脂血症比率,AMI发病至就诊时间,急诊冠状动脉再灌注治疗比率,心肌梗死部位,病变血管数,AMI后并发VSR时间,VSR直径,VSR部位,入CCU后血小板计数、C-反应蛋白、血肌酐、B型脑利钠肽、肌钙蛋白I、血乳酸水平,左室射血分数、左心室舒张末期内径及有室壁瘤比率比较差异均无统计学意义(P>0.05)。白细胞计数(OR=1.141,95%CI:1.033~1.262,P=0.001)、SOFA评分(OR=1.510,95%CI:1.165~1.957,P=0.002)、室间隔缺损封堵术(OR=0.060,95%CI:0.013~0.287,P<0.001)是行IABP治疗AMI后并发VSR患者院内死亡的影响因素。结论 行IABP辅助治疗AMI后并发VSR患者院内病死率高,入CCU时白细胞计数、SOFA评分增高者院内死亡风险增加。

Objective To observe the efficacy of intra-aortic balloon pump(IABP)adjuvant therapy on ventricular septal rupture(VSR)in patients with acute myocardial infarction (AMI),and to investigate the influencing factors of in-hospital death.Methods Ninety-four patients with VSR secondary to AMI received IABP adjuvant therapy on the basis of conventional drug therapy,in which 56 patients died in hospital(death group)and 38 survived(survival group).The underlying diseases,time from AMI onset to visit,myocardial infarction site,percentage of patients receiving emergency coronary reperfusion therapy,VSR time secondary to AMI,VSR diameter,VSR site and other general data were compared between two groups.The sequential organ failure assessment(SOFA)score,white blood cell count,blood lactate,left ventricular ejection fraction,left ventricular end-diastolic dimension and other clinical data were recorded.The time of IABP adjuvant therapy,and the percentages of patients receiving ECMO adjuvant therapy,ventilator adjuvant therapy,continuous renal replacement therapy and ventricular septal closure after entering CCU were compared between two groups.Multivariate logistic regression analysis was used to evaluate the influencing factors of in-hospital death after IABP adjuvant therapy in patients with VSR secondary to AMI.Results The SOFA score after entering into CCU,white blood cell count and blood lactic acid level were higher in death group[11.5±3.8,(15.3±4.9)×10^(9)/L,4.6 (2.1,6.1)mmol/L]than those in survival group[6.2±2.1,(12.5±4.5)×10^(9)/L,1.5(1.1,2.2)mmol/L](P<0.05),the percentages of patients receiving ECMO,ventilator and continuous renal replacement therapy were significant higher in death group (17.9%,57.1%,51.8%)than those in survival group(2.6%,21.6%,18.4%)(P<0.05),the percentage of patients receiving ventricular septal closure was lower in death group(25.0%)than that in survival group (86.8%)(P<0.05),and there were no significant differences in the percentages of patients with hypertension,diabetes and hyperlipidemia,the time from AMI onset to visit,the percentage of patients receiving emergency coronary reperfusion therapy,the myocardial infarction site,the number of diseased vessels,the time,diameter and location of VSR after AMI,the platelet count,C-reactive protein level,creatinine level,B-type brain natriuretic peptide level,troponin I level and lactate level after entering CCU,the left ventricular ejection fraction,the left ventricular end-diastolic dimension and the percentage of patients with aneurysm between two groups(P>0.05).White blood cell count(OR=1.141,95%CI:1.033-1.262,P=0.001),SOFA score (OR=1.510,95%CI:1.165-1.957,P=0.002)and ventricular septal closure(OR=0.060,95%CI:0.013-0.287,P<0.001)were the influencing factors of in-hospital death after IABP in patients with VSR secondary to AMI.Conclusion The in-hospital death rate is high in patients with VSR secondary to AMI after IABP adjuvant treatment,and the risk of in-hospital death increases in patients with increased white blood cell count and SOFA score at CCU.