急性肺栓塞外科治疗可行性分析及DD/cTnI价值探索

Feasibility analysis of surgical treatment of acute pulmonary embolism and exploration of DD/cTnI value

目的探讨肺栓塞外科治疗的可行性及D-二聚体(DD)与肌钙蛋白I(cTnI)比值在肺栓塞治疗中的指导价值。方法收集安徽医科大学第一附属医院2016年1月到2021年10月确诊急性肺栓塞(acute pulmonary embolism,APE)患者临床资料,行外科血栓切除术治疗APE患者纳入外科治疗组,行抗凝、溶栓治疗APE患者纳入内科治疗组。结果1.本次共纳入确诊为APE患者269例,男性141(52.41%)例,女性128(47.58%)例,平均年龄为(60.51±11.39)岁。2.肺栓塞常见临床表现是胸闷、胸痛、咳嗽、呼吸困难,常见危险因素及合并症是下肢深静脉血栓、卧床及肺部感染、高血压。3.两组危险因素分析:肺部感染、长期卧床、下肢骨折方面有统计学差异(P<0.05)。4.两组临床资料的比较:外科治疗组与内科治疗组在年龄、急诊入院、住院天数、医疗费用、出现低血压或休克、循环中血栓、药物治疗失败、严重右心功能不全、严重右心功能不全合并近期手术方面,差异有统计学意义(P<0.05)。5.两组生物标记物比较:外科治疗组DD、cTnI水平显著高于内科治疗组,而外科治疗组DD/cTnI水平显著低于内科治疗组(P<0.05)。6.ROC曲线分析肺栓塞外科治疗的生物标志物:DD的最佳截断值为14.79ug/mL(AUC=0.60,敏感性41.67%,特异性77.44%),cTnI的最佳截断值为0.04ng/mL(AUC=0.66,敏感性68.75%,特异性63.41%),以及DD/cTnI比值最佳截断值是133×103(AUC=0.65,敏感性60.42%,特异性70.73%)。7.外科治疗组出院好转55例(96.49%),围术期死亡2例(3.50%)。结论APE在出现低血压或休克、循环中血栓、药物治疗失败、药物治疗禁忌、严重右心功能不全、严重右心功能不全合并近期手术时,多学科会诊后可选择外科治疗。cTnI及DD/cTnI用于预测肺栓塞外科治疗显示出比DD更高的敏感性,可作为肺栓塞外科治疗的参考指标。

Objective To investigate the feasibility of pulmonary embolism treated surgically and the guiding value of D-dimer(DD)and troponin I(cT nI)ratio in treatment of pulmonary embolism.Methods The clinical data of patients from the First Affiliated Hospital of Anhui Medical University from January 2016 to October 2021 who was diagnosed with acute pulmonary embolism(APE)were collected.Those APE patients treated with surgical thrombectomy were included in the surgical treatment group,and the rest APE patients treated with anticoagulation and thrombolysis were included in the medical treatment group.Results 1.A total of 269 patients with APE were enrolled,including 141 males(52.41%)and 128 females(47.58%),with an average age of(60.51±11.39)years old.2.Their common clinical manifestations of pulmonary embolism were chest tightness,chest pain,cough,dyspnea,and the common risk factors and comorbidities were lower extremity deep vein thrombosis,bed rest,lung infection and hypertension.3.There were significant differences in the risk factors of pulmonary infection,long-term bed,and lower limb fractures between the two groups(P<0.05).4.There was no statistically significant difference in gender and recent operation between the two groups(P<0.05).There were statistically significant differences in age,emergency hospitalization,hospitalization days,medical expenses,hypotension or shock,circulatory thrombosis,drug treatment failure,severe right heart failure,and severe right heart failure combined with recent operation between the surgical treatment group and the medical treatment group(P<0.05).5.The DD and cT nI level in the surgical treatment group was significantly higher than that in the medical treatment group,while the DD/cT nI level in the surgical treatment group was significantly lower than that in the medical treatment group(P<0.05).6.ROC curve analysis showed that the optimal cut-off value of DD was 14.79 ug/mL(AUC=0.60,sensitivity 41.67%,specificity 77.44%),the optimal cut-off value of cT nI was 0.04 ng/mL(AUC=0.66,sensitivity 68.75%,specificity 63.41%),and the optimal cut-off value of DD/cT nI ratio was 133×103(AUC=0.65,sensitivity 60.42%,specificity 70.73%).7.In the surgical treatment group,55 cases(96.49%)were improved and 2 cases(3.50%)died during the perioperative period.Conclusion APE is treated surgically after multidisciplinary consultation in the presence of hypotension or shock,presence of thrombus in the circulation,failure of drug therapy,contraindications to drug therapy,severe right heart insufficiency,and severe right heart insufficiency combined with recent surgery.cT nI and DD/cT nI show higher sensitivity than DD in predicting surgical treatment of pulmonary embolism,which can be used as a reference index for surgical treatment of pulmonary embolism.