急性A型主动脉夹层患者术前血清N-末端B型利钠肽原、血肌酐、D-二聚体联合监测及预后分析

Preoperatively combined monitoring of serum N-terminal pro-B-type natriuretic peptide, serum creatinine, D-dimer and prognosis analysis in patients with acute type A aortic dissection

目的探讨急性Stanford A型主动脉夹层(ATAAD)患者术后死亡的危险因素, 分析血清N-末端B型利钠肽原(NT-proBNP)、血肌酐(Scr)、D-二聚体(D-D)联合监测在预后评估中的价值。方法手术治疗ATAAD患者317例, 追踪术后30 d生存情况, 死亡58例为死亡组, 生存259例为生存组。比较两组一般治疗、实验室结果、手术方式及术后并发症;多因素Logistic回归分析手术治疗的ATAAD患者术后30 d死亡的影响因素;绘制受试者工作特征(ROC)曲线, 评估NT-proBNP、Scr、D-D预测ATAAD患者术后30 d死亡的效能。结果生存组NT-proBNP[(174.74±37.40) pg/ml]低于死亡组[(306.49±62.25) pg/ml]、生存组Scr[(94.27±22.17) μmol/L]低于死亡组[(137.71±27.28) μmol/L]、生存组D-D[(0.61±0.10) mg/L]低于死亡组[(0.86±0.15) mg/L, P<0.05];NT-proBNP[比值比(OR)=1.12, 95%可信区间(CI):1.02~1.23)、Scr(OR=1.16, 95%CI:1.01~1.33)、D-D(OR=14.78, 95%CI:14.71~14.83)是ATAAD患者术后30 d内死亡的危险因素。NT-proBNP以238.950为最优截断值, 预测ATAAD患者术后30 d内死亡的曲线下面积为0.913(95%CI:0.864~0.960, P<0.01), 灵敏度为89.7%, 特异度为93.8%;D-D以0.765为最优截断值, 预测ATAAD患者术后30 d内死亡的曲线下面积为0.913(95%CI:0.878~0.950, P<0.01), 灵敏度为79.3%, 特异度为95.0%、Scr以109.125为最优截断值, 预测ATAAD患者术后30 d内死亡的曲线下面积为0.960(95%CI:0.925~1.000, P<0.01), 灵敏度为89.7%, 特异度为77.6%, 三者联合预测ATAAD患者术后30 d内死亡的曲线下面积为0.997(95%CI:0.993~1.000, P<0.01), 灵敏度为96.6%, 特异度为98.5%。结论 NT-proBNP、Scr、D-D升高与ATAAD患者术后30 d内死亡有关, 三者联合在预测手术治疗的ATAAD患者术后30 d死亡中有较高价值。

Objective To investigate the risk factors of postoperative mortality in patients with acute Stanford type A aortic dissection(ATAAD),and to analyze the value of combined monitoring of serum N-terminal pro-B-type natriuretic peptide(NT-proBNP)and D-dimer(D-D)in prognosis assessment.Methods A total of 317 patients with ATAAD were treated by surgery,and the 30-day survival after operation was tracked.A total of 58 patients died in death group and 259 patients survived in survival group.The general treatment,laboratory results,surgical methods and postoperative complications were compared between the two groups.Multivariate Logistic regression analysis was used to analyze the influencing factors of postoperative 30-day death in ATAAD patients.The receiver operating characteristic(ROC)curve was drawn to evaluate the efficacy of NT-proBNP,D-D and serum creatinine(Scr)in predicting the 30-day postoperative death of ATAAD patients undergoing surgical treatment.Results The NT-proBNP,Scr and D-D in the survival group were lower than in the death group[(174.74±37.40)vs.(306.49±62.25)pg/ml;(94.27±22.17)vs.(137.71±27.28)μmol/L;(0.61±0.10)vs.(0.86±0.15)mg/L,P<0.05].NT-proBNP[odds ratio(OR)=1.12,95%confidence interval(CI):1.02-1.23]and Scr(OR=1.16,95%CI:1.01-1.33)were risk factors for death within 30 days after ATAAD.With 238.950 as the optimal cut-off value,the area under the curve of NT-proBNP was 0.913(95%CI:0.864-0.960,P<0.01),the sensitivity was 89.7%,and the specificity was 93.8%.For D-D,0.765 was the optimal cut-off value,and the area under the curve for predicting the death of ATAAD patients within 30 days after surgery was 0.913(95%CI:0.788-0.950,P<0.01),the sensitivity was 79.3%,the specificity was 95.0%.The optimal cutoff value of Scr was 109.125,and the area under the curve for predicting the death of ATAAD patients within 30 days after surgery was 0.960(95%CI:0.925-1.000,P<0.01),the sensitivity was 89.7%,and the specificity was 77.6%.The area under the curve of combined prediction of death within 30 days after ATAAD was 0.997(95%CI:0.993-1.000,P<0.01),the sensitivity and specificity were 96.6%and 98.5%,respectively.Conclusion The increase of NT-proBNP,D-D and Scr is related to the death within 30 days after surgery in ATAAD patients.The combination of the three factors has a high value in predicting the death within 30 days after surgery in ATAAD patients.