心脏瓣膜疾病患者术后发生消化道大出血的危险因素分析

Risk factors of in-hospital major gastrointestinal bleeding in patients underwent heart valvular surgery

目的 探讨心脏瓣膜疾病患者术后住院期间发生消化道大出血对预后的影响及其危险因素。方法 纳入首都医科大学附属北京安贞医院2016年1月1日至2022年7月31日术后住院期间发生消化道大出血的131例心脏瓣膜疾病患者作为研究组,并按1:2选取接受相同手术方式且未发生消化道大出血的271例心脏瓣膜疾病患者作为对照组。比较两组患者基础疾病、手术相关指标、术后并发症及预后等临床资料。采用单因素和多因素logistic回归分析探讨心脏瓣膜疾病患者术后住院期间发生消化道大出血的危险因素,并绘制受试者工作特征(receiver operating characteristic,ROC)曲线,计算曲线下面积(area under the curve,AUC),评估患者术后住院期间发生消化道大出血对预后的影响。结果 心脏瓣膜疾病患者术后住院期间发生消化道大出血的危险因素包括重症肺炎(OR=7.293,95%CI 3.545~15.004,P<0.001)、Ⅱ期或Ⅲ期急性肾功能不全(OR=4.219,95%CI2.245~7.932,P<0.001)、术后凝血功能异常(OR=3.205,95%CI1.648~6.231,P=0.001)、应用华法林(OR=0.236,95%CI0.106~0.524,P<0.001)、既往心房颤动(OR=1.869,95%CI1.015~3.441,P=0.045)、心脏手术(OR=2.079,95%CI1.037~4.166,P=0.039)和术前射血分数降低(OR=0.964,95%CI0.934~0.995,P=0.023),联合上述指标绘制ROC曲线,其AUC为0.870(95%CI 0.829~0.912,P<0.001)。研究组患者的死亡率(20.6%)、病重转院率(42.7%)和术后住院天数[(20.76±15.85)d]均高于对照组[分别为1.1%,5.2%,(9.47±4.86)d],差异有显著性(P<0.001)。结论 心脏瓣膜疾病患者术后住院期间发生消化道大出血与死亡率增加和住院时间延长相关。重症肺炎、Ⅱ期或Ⅲ期急性肾功能不全、术后凝血功能异常、应用华法林、既往心房颤动、心脏手术和术前射血分数降低是心脏瓣膜疾病患者术后住院期间发生消化道大出血的危险因素。

Objective To investigate the prognostic effects and risk factors of gastrointestinal major bleeding during hospitalization after heart valvular surgery.Method A total of 131 patients with heart valvular disease who suffered major gastrointestinal bleeding during postoperative hospitalization in Beijing Anzhen Hospital affiliated to Capital Medical University from January 1,2016 to July 31,2022 were included as the study group,and 271 patients with heart valvular disease who received the same surgical method and did not suffer massive gastrointestinal bleeding were selected as the control group at a rate of 1:2.The underlying diseases,operation-related indicators,postoperative complications and prognosis of these patients were compared between the two groups.Univariate and multivariate logistic regression analysis were used to explore the risk factors of major gastrointestinal bleeding in patients with heart valvular disease during postoperative hospitalization.The receiver operating characteristic(ROC)curve of subjects was drawn and the area under the curve(AUC)was calculated to evaluate the influence of major gastrointestinal bleeding on the prognosis of patients during postoperative hospitalization.Result Predictors of major gastrointestinal bleeding during hospitalization after heart valvular surgery were severe pneumonia(OR=7.293,95%CI 3.545-15.004,P<0.001),stageⅡorⅢacute renal insufficiency(OR=4.219,95%CI 2.245-7.932,P<0.001),postoperative coagulation abnormalities(OR=3.205,95%CI 1.648-6.231,P=0.001),warfarin usage(OR=0.236,95%CI 0.66-0.524,P<0.001),previous cardiac surgery(OR=2.079,95%CI 1.037-4.166,P=0.039),atrial fibrillation(OR=1.869,95%CI 1.015-3.441,P=0.045)and reduced preoperative ejection fraction(OR=0.964,95%CI 0.934-0.995,P=0.023).The ROC curve was drawn and the AUC was 0.870(95%CI 0.829-0.912,P<0.001).The mortality rate(20.6%),transfer rate of serious illness(42.7%)and length of stay after surgery[20.76±15.85]in the study group were higher than those in the control group[1.1%,5.2%,(9.47±4.86)d,respectively],these differences were significant(P<0.001).Conclusion In-hospital major gastrointestinal bleeding after heart valvular surgery was associated with increased mortality and length of stay.Severe pneumonia,stageⅡorⅢacute renal insufficiency,postoperative coagulation abnormalities,warfarin use,prior cardiac surgery,atrial fibrillation,and decreased preoperative ejection fraction were risk factors of major gastrointestinal bleeding during postoperative hospitalization in patients with heart valvular surgery.