二尖瓣置换同期行心房颤动射频消融术死亡相关风险因素分析

Risk factors related to death during mitral valve replacement and concurrent radiofrequency ablation for atrial fibrillation

目的探讨心脏外科手术同期行心房颤动射频消融死亡的风险因素。方法选取2003年1月至2023年1月于云南省第一人民医院心外科收治的二尖瓣狭窄合并心房颤动患者90例,行二尖瓣置换术同期行心房颤动射频消融术。根据手术结果分为手术成功组(n=70)和术后死亡组(n=20)。收集两组患者术前一般基线资料,包括性别、年龄、高血压、糖尿病、卒中(或短暂性脑缺血发作)史、吸烟史、慢性阻塞性肺疾病(COPD)史、心房颤动类型(持续性心房颤动、永久性心房颤动)、纽约心功能分级、射血分数、左房大小、术前肺动脉高压程度、术前血小板数量、血红蛋白及术中主动脉阻断心脏停跳时间。利用独立样本t检验及单因素Logistic回归分析对两组患者术前及术中数据资料进行统计分析,以明确心脏外科手术同期行心房颤动射频消融死亡的风险因素。结果两组患者在性别、年龄、高血压史、糖尿病史、卒中(或短暂性脑缺血发作)、吸烟史、合并慢性阻塞性肺气肿(COPD)史等方面比较,均无显著性差异(P>0.05)。与手术成功组相比,术后死亡组患者永久性心房颤动、纽约心功能Ⅱ级以上及射血分数≤45%比例高(P<0.05),左房直径>6 mm、术前肺动脉高压程度>50 mmHg(1 mmHg=0.133 kPa)、术前60 g/L≤血红蛋白计数≤80 g/L比例高(P<0.05),术中心脏停跳时间>100 min比例高(P<0.05)。单因素Logistic回归分析结果表明,永久性心房颤动、纽约心功能Ⅱ级以上、射血分数≤45%,左房直径>6mm、术前肺动脉高压>50mmHg、术前60g/L≤血红蛋白≤80g/L及术中心脏停跳时间>100min与心脏外科手术同期行心房颤动射频消融死亡有独立的关联。结论术前患者为永久性心房颤动、心功能Ⅱ级以上、射血分数≤45%、左房直径>6mm、肺高压>50mmHg、术前血红蛋白值≤80 g/L以及预计术中心脏停跳时间>100 min,这些因素均可增加患者手术的死亡风险。当患者术前及术中各项指标达到上述指标时,建议慎重考虑心脏外科手术同期行术中心房颤动射频消融术。

Objective To discuss the risk factors related to death during cardiac surgery and concurrent radiofrequency ablation(RFA)for atrial fibrillation(AF).Methods The patients with mitral stenosis complicated by AF(n=90)were chosen from Department of Cardiovascular Surgery in the First People’s Hospital of Yunnan Province from Jan.2003 to Jan.2023,and were received mitral valve replacement and concurrent RFA for AF.According to surgical results,the patients were divided into successful surgery group(n=70)and postoperative death group(n=20).The preoperative baseline materials were collected in 2 groups,including gender,age,with or without history of hypertension,diabetes,stroke[or transient ischemic attack(TIA)]smoking,and chronic obstructive pulmonary disease(COPD),AF types[persistent atrial fibrillation(PeAF),permanent AF],grades of NYHA heart function classification(NYHA grades),ejection fraction(EF),left atrial size,preoperative severity of pulmonary arterial hypertension(PAH),preoperative platelet count(PLT),hemoglobin(Hb)content,and cardiac arrest time of aortic occlusion during the surgery.All preoperative and intraoperative data were analyzed statistically by using independent sample t-test and single-factor Logistic regression analysis to determine risk factors for death during cardiac surgery and concurrent RFA.Results There were no significant differences in gender,age and history of hypertension,diabetes,stroke(or TIA),smoking and complicated COPD between 2 groups(P>0.05).The percentages of patients with permanent AF,NYHA gradeⅡor above and EF≤45%(P<0.05),left atrial diameter(LAD)>6 mm,and preoperative PAH>50 mmHg and 60 g/L≤Hb content<80 g/L(P<0.05),and cardiac arrest time>100 min during the surgery(P<0.05)were higher in successful surgery group than those in postoperative death group.The results of single-factor Logistic regression analysis showed that permanent AF,NYHA gradeⅡor above,EF≤45%,LAD>6 mm,preoperative PAH>50 mmHg and 60 g/L≤Hb content≤80 g/L and cardiac arrest time>100 min were correlated to death during cardiac surgery and concurrent RFA for AF.Conclusion The factors of permanent AF,NYHA gradeⅡor above,EF≤45%,LAD>6 mm,preoperative PAH>50 mmHg and Hb content≤80 g/L,and cardiac arrest time>100 min can increase death risk during the operation.When preoperative and intraoperative indexes reach the above targets,it is recommended to carefully consider performing concurrent RFA for AF during cardiac surgery.