急性A型主动脉夹层术后乳酸水平及恢复与预后的关系

Relationship between lactate level, recovery and prognosis after acute type A aortic dissection

目的 分析急性A型主动脉夹层(acute Stanford type-A aortic dissection,aTAAD)术后乳酸水平及恢复与预后的关系。方法 对2020年1月至2021年6月在西安交通大学第一附属医院心血管外科住院行外科手术治疗的aTAAD患者进行筛选并随访半年,共纳入患者293例,其中仅行手术治疗患者263例,随访半年,失访4例,最终纳入符合研究标准的患者259例患者,其中男性176例,女性83例,年龄(51±12)岁,按照随访截止是否死亡分为死亡组和存活组,死亡组患者59例,存活组200例。所有患者均检测术后(0、4、8、12、16、20与24)h的乳酸水平,计算乳酸恢复至正常水平所需时间,术前空腹抽血留取生化、血常规及凝血等指标,记录超声心动图等指标。结果 通过不同指标单因素和多因素COX比较发现,术后24 h乳酸[HR 0.805,95%CI (0.708,0.916),P<0.01]、乳酸恢复至正常水平所需时间[HR 1.066,95%CI (1.039,1.094),P<0.01]、DD[HR 1.052,95%CI (1.023,1.082),P<0.01]及年龄[HR 1.047,95%CI (1.015,1.081),P<0.01]均为影响aTAAD患者的影响因素。乳酸恢复正常水平所需时间的ROC曲线下面积(AUC)为0.789[95%CI (0.656,0.801)],灵敏度为83.1%,特异度为59.5%(P<0.01),通过比较曲线下面积发现乳酸恢复正常水平所需时间预测价值大于其余指标。将患者分为乳酸恢复至正常水平所需时间<21 h组和乳酸恢复至正常水平所需时间>21 h组,进一步绘制影响aTAAD患者预后的生存曲线,发现乳酸恢复至正常水平所需时间<21 h组患者存活率大于乳酸恢复至正常水平所需时间>21 h组,且Log Rank检验P<0.01。结论 a TAAD术后24 h乳酸和乳酸恢复至正常水平所需时间是影响长期预后的独立影响因素,且乳酸恢复至正常水平所需时间预测价值优于单一乳酸水平,是最佳的预后指标,为临床提前干预和治疗提供依据。

AIM To analyze the relationship between lactate level, recovery and prognosis after acute Stanford type-A aortic dissection(aTAAD). METHODS From January 2020 to June 2021, aTAAD patients who underwent surgical treatment in the Department of cardiovascular surgery of the First Affiliated Hospital of Xi’an Jiaotong University were screened and followed up for half a year. A total of293 patients were included, including 263 patients who underwent surgical treatment only, 4 patients who were followed up for half a year, and 259 patients who met the research criteria, including 176 males and83 females, The age was(51 ± 12) years old. They were divided into death group and survival group according to whether they died at the end of follow-up. There were 59 patients in the death group and 200patients in the survival group. All patients were tested for lactate levels at 0, 4, 8, 12, 16, 20 and 24 hours after operation, and the time required for lactate to return to normal level was calculated. Before operation, blood samples were drawn on an empty stomach, biochemical, blood routine and coagulation indexes were taken, and echocardiography and other indexes were recorded. RESULTS Through the comparison of univariate and multivariate COX of different indexes, it was found that lactate [HR 0.805,95% CI(0.708,0.916), P<0.01], the time required for lactate to return to normal level [HR 1.066, 95% CI(1.039,1.094), P<0.01], DD [HR 1.052, 95% CI(1.023,1.082), P<0.01] and age [HR 1.047, 95% CI(1.015,1.081), P<0.01] were the influencing factors of aTAAD patients. The area under the ROC curve(AUC) of the time required for lactic acid to return to normal level was 0.789 [95% CI(0.656,0.801)], the sensitivity was 83.1%, and the specificity was 59.5%(P<0.01). By comparing the area under the curve, it was found that the predictive value of the time required for lactic acid to return to normal level was greater than other indexes. The patients were divided into two groups: the time required for lactic acid to return to the normal level <21 h group and the time required for lactic acid to return to the normal level >21 h group. The survival curve affecting the prognosis of aTAAD patients was further drawn. It was found that the survival rate of patients in the time required for lactic acid to return to the normal level <21 h group was higher than that in the time required for lactic acid to return to the normal level >21 h group, and log rank test P<0.01. CONCLUSION Lactic acid 24 hours after aTAAD and the time required for lactic acid to return to normal level are independent factors affecting the long-term prognosis, and the predictive value of the time required for lactic acid to return to normal level is better than lactic acid level alone. The predictive value of the time required for lactic acid to return to normal level is the best prognostic indicator and it provides a basis for early clinical intervention and treatment.