主动脉夹层围手术期及远期全因病死率的影响因素分析

Analysis of influencing factors of perioperative and long-term all-cause mortality in patients with aortic dissection

目的分析主动脉夹层(AD)患者围手术期及远期全因病死率的影响因素,为改善AD患者预后和降低病死率提供依据.方法选择2015年1月至2020年6月在湖北文理学院附属医院/襄阳市中心医院接受手术治疗的AD患者1066例作为研究对象.按是否发生围手术期死亡和是否发生出院后随访期间死亡,将患者分为围手术期死亡组和存活组、随访期间死亡组和存活组.收集患者的临床资料,一般资料包括:性别、年龄、主要慢性疾病患病情况(高血压、糖尿病、冠心病等)、是否吸烟、饮酒等,临床资料包括入院时生命体征[心率(HR)、收缩压、舒张压、胸痛等]和术前实验室检查资料[血红蛋白(Hb)、白细胞计数(WBC)、血小板计数(PLT)、中性粒细胞/淋巴细胞比值(NLR)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、白蛋白(ALB)、血肌酐(SCr)、肌酸激酶同工酶(CK-MB)、C-反应蛋白(CRP)、D-二聚体]、有无胸腔积液和心包积液、AD类型(Stanford A型、Stanford B型)、手术治疗方式(主动脉腔内隔绝术、外科手术和杂交手术)等;比较不同预后两组患者上述指标的差异,并随访终点事件(定义为住院期间全因死亡及出院后随访期间全因死亡),分别采用Logistic回归模型和Cox回归模型分析AD患者围手术期及远期全因死亡的影响因素.结果1066例AD患者围手术期院内病死率为13.23%(141/1066),随访期间全因病死率19.51%(208/1066),出院后第1、2、3年的生存率分别为92.07%、81.36%、71.46%.随访期间失访63例,最终死亡组纳入349例,存活组纳入654例.死亡组AD患者的年龄、合并高血压的比例、吸烟人群比例、饮酒人群比例、入院时HR、收缩压、胸痛比例、术前NLR、SCr、D-二聚体、入院时有胸腔积液和心包积液比例、夹层类型为Stanford A型比例、外科手术治疗比例均明显高于存活组(均P<0.05),而入院时舒张压、术前Hb均明显低于存活组(均P<0.05).多因素Logistic回归分析显示:入院时HR增快[优势比(OR)=1.061,95%可信区间(95%CI)为1.026~1.097]、临床症状有胸痛(OR=2.120,95%CI为1.117~4.024)、术前高NLR水平(OR=1.175,95%CI为1.061~1.301)、入院时有胸腔积液(OR=8.432,95%CI为5.330~13.338)、心包积液(OR=13.437,95%CI为9.897~18.243)、Stanford A型AD(OR=5.714,95%CI为4.209~7.758)是影响围手术期患者院内死亡的独立危险因素(均P<0.05);而入院时舒张压水平偏高则是AD患者围手术期院内死亡的保护因素(OR=0.925,95%CI为0.907~0.943,P<0.05).多因素Cox回归分析显示:年龄越大[风险比(HR)=1.053,95%CI为1.029~1.078]、入院时HR增快(HR=1.106,95%CI为1.081~1.133)、临床症状有胸痛(HR=1.677,95%CI为1.384~2.032)、术前高D-二聚体水平(HR=2.030,95%CI为1.633~2.523)、Stanford A型AD(HR=4.609,95%CI为3.252~6.533)是AD患者出院后长期预后的独立危险因素(均P<0.05).结论入院时HR增快、临床症状有胸痛、术前高NLR水平、入院时有胸腔积液、心包积液、AD类型为Stanford A型是患者围手术期院内死亡的独立危险因素;年龄越大、入院时HR增快、临床症状有胸痛、术前高D-二聚体水平、AD类型为Stanford A型是患者出院后长期预后的独立危险因素.

Objective To investigate the perioperative and long-term all-cause mortality and its influencing factors in patients with aortic dissection(AD),and to provide the basis for improving the prognosis and reducing the mortality of AD patients.Methods A total of 1066 AD patients who underwent surgical treatment in the Affiliated Hospital of Hubei University of Arts and Sciences&Xiangyang Central Hospital from January 2015 to June 2020 were selected as the study subjects.According to whether there was perioperative death and whether death occurred during follow-up after discharge,patients were divided into perioperative death group and survival group,death group and survival group during follow-up.Clinical data of patients were collected,general data included:gender,age,prevalence of major chronic diseases(hypertension,diabetes,coronary heart disease,etc.),smoking,drinking,etc.,clinical data included:vital signs at admission[heart rate(HR),systolic pressure,diastolic pressure,chest pain,etc.]and preoperative laboratory examination data[hemoglobin(Hb),white blood cell count(WBC),platelet count(PLT),neutrophil/lymphocyte ratio(NLR),alanine aminotransferase(ALT),aspartate aminotransferase(AST),albumin(ALB),serum creatinine(SCr),MB isoenzyme of creatine kinase(CK-MB),C-reactive protein(CRP),D-dimerl,presence or absence of pleural and pericardial effusion,type of dissection(Stanford A,Stanford B),surgical treatment methods(aortic endovascular isolation,surgery,and hybrid surgery),etc.The differences in the above indicators between the two groups of patients with different prognosis,and the follow-up end point events(defined as all-cause death during hospitalization and all-cause death during follow-up after discharge)were compared.Logistic regression model and Cox regression model were used to analyze the influencing factors of perioperative and long-term all-cause death in AD patients.Results The perioperative hospital mortality rate of 1066 AD patients was 13.23%(141/1066),and the all-cause mortality rate during the follow-up period was 19.51%(208/1066)].The survival rates for the first,second,and third years after discharge were 92.07%,81.36%,and 71.46%,respectively.During the follow-up period,63 cases were lost to follow-up.Finally,349 cases were included in the death group and 654 cases in the survival group.The age of AD patients in the death group,the proportion of patients with hypertension,the proportion of smokers,the proportion of drinkers,HR at admission,systolic blood pressure,chest pain,preoperative NLR,SCr,D-dimer,the proportion of pleural effusion and pericardial effusion at admission,the proportion of Stanford type A AD,and the proportion of surgical treatment were significantly higher than those in the survival group(all P<0.05),while diastolic blood pressure at admission and the preoperative Hb was significantly lower in the survival group(both P<0.05).Multivariate Logistic regression analysis showed that HR increased rapidly at admission[odds ratio(OR)=1.061,95%confidence interval(95% CI)was 1.026-1.097],clinical symptoms of chest pain(0R=2.120,95% CI was 1.117-4.024),preoperative high NLR levels(OR=1.175,95%CI was 1.061-1.301),pleural effusion at admission(OR=8.432,95%CI was 5.330-13.338),pericardial effusion(OR=13.437,95%CI was 9.897-18.243),Stanford type A AD(OR=5.714,95% CI was 4.209-7.758)were independent risk factors for perioperative mortality in patients(all P<0.05).High diastolic blood pressure at admission was a protective factor for perioperative mortality in AD patients(OR=0.925,95% CI was 0.907-0.943,P<0.05).Multivariate Cox regression findings showed that older age[hazard ratio(HR)=1.053,95%CI was 1.029-1.078],faster HR at admission(HR=1.106,95%CI was 1.081-1.133),clinical symptoms of chest pain(HR=1.677,95%CI was 1.384=2.032),high preoperative D-dimer levels(HR=2.030,95%CI was 1.633-2.523),Stanford type A AD(HR=4.609,95%CI was 3.252-6.533)were independent risk factors for the long-term prognosis of patients after discharge(all P<0.05).Conclusions Increased HR at admission,clinical symptoms of chest pain,high preoperative NLR levels,pleural effusion,pericardial effusion,and Stanford type A AD were independent risk factors for perioperative mortality in AD patients.Older age,faster HR at admission,clinical symptoms such as chest pain,high preoperative D-dimer levels,and Stanford type A AD are independent risk factors for long-term prognosis and death in patients after discharge.