急性Stanford A型主动脉夹层中低温停循环手术围手术期大量出血的危险因素分析  

Analysis of risk factors for massive bleeding in patients with acute Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest repair

作　　者：葛翼鹏[1] 里程楠[1] 钟永亮[1] 夏瑀[1] 肖付诚 郑军[1] 刘永民[1] 朱俊明[1] 孙立忠[1] Ge Yipeng;Li Chengnan;Zhong Yongliang;Xia Yu;Xiao Fucheng;Zheng Jun;Liu Yongmin;Zhu Junming;Sun Lizhong(Department of Cardiovascular Surgery,Beijing Aortic Disease Center,Beijing Anzhen Hospital Capital Medical University,Beijng 100029,China)

机构地区：[1]首都医科大学附属北京安贞医院心血管外科,100029

出　　处：《中华胸心血管外科杂志》2021年第5期281-285,共5页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：国家自然基金面上项目(81970393);北京市医院管理中心青苗计划专项(QML20190608);北京市科委-首都临床诊疗技术研究及示范应用(Z19110700660000);北京市科技重大专项课题(Z171100001017083)。

摘　　要：目的研究急性Stanford A型主动脉夹层中低温停循环手术围手术期大量出血的危险因素。方法2016年1月至2017年10月连续486例急性A型主动脉夹层患者纳入研究。所有手术均在中低温停循环下进行。回顾性收集患者的基本临床资料,分别以成人心脏手术出血定义(universal definition of perioperative bleeding,UDPB)4级和血液保护抗纤溶药物随机试验(the blood conservation using antifibrinolytics in a randomized trial,BART)定义的大量出血为终点事件。将单因素分析有意义的变量纳入多元logistic回归。结果院内死亡34例(7.00%)。187例(38.48%)符合BART大量出血定义。UDPB分级0级45例(9.26%),1级8例(1.65%),2级114例(23.46%),3级147例(30.25%),4级172例(35.39%)。以BART标准为终点事件,多因素logistic回归结果显示女性(OR=3.32,P<0.001)、贫血(OR=2.24,P=0.04)、肌酐清除率≤85 ml/min(OR=1.93,P=0.01)、D-二聚体每增加500 ng/ml(OR=1.02,P=0.003)、体外循环(OR=1.01,P<0.001)、全主动脉弓替换(OR=2.40,P=0.02)为大量出血的独立危险因素,发病至手术的时间(OR=0.86,P=0.01)为保护性因素。以UDPB 4级为终点事件,多因素logistic回归结果显示女性(OR=2.43,P<0.0013),肌酐清除率≤85 ml/min(OR=2.05,P=0.001),D-二聚体每增加500 ng/ml(OR=1.01,P=0.04),体外循环(OR=1.01,P<0.001)为大量出血的独立危险因素。发病至手术的时间(OR=0.85,P=0.002)和主动脉根部术式为Bentall(OR=0.65,P=0.04)为保护性因素。结论急性Stanford A型主动脉夹层手术大量出血较为多见。女性、较差的肾功能、高D-二聚体水平、发病早期外科手术、长时间体外循环为共同的独立危险因素。对于高危患者,应采取简单、有效的的手术方式降低出血风险。Objective To study the risk factors of massive bleeding in patients with acute Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest repair.Methods From January 2016 to October 2017,486 consecutive patients with acute type A aortic dissection were included in the study.All operations were performed with moderate hypothermic circulatory arrest.The basic clinical data of patients were collected retrospectively.Massive bleeding was defined according to definition of Universal Definition of Perioperative Bleeding(UDPB)4 class and the Blood Conservation Using Antifibrinolytics in a Randomized Trial(BART).Significant variables in univariate analysis were included in multivariate logistic regression analysis.Results Thirty-four patients(7.00%)died in hospital.A total of one hundred and eighty-seven patients(38.48%)fulfilled criteria of the definition of BART massive bleeding.Forty-five patients(9.26%),8 patients(1.65%),114 patients(23.46%),147 patients(30.25%)and 172 patients(35.39%)were in grade 0,grade 1,grade 2 and grade 4,respectively.With BART as the end point,the result of multivariate logistic regression showed that female gender(OR=3.32,P<0.001),anemia(OR=2.24,P=0.04),clearance creatine≤85 ml/min(OR=1.93,P=0.01),D-dimer level(every 500 ng/ml increase,OR=1.02,P=0.003),cardiopulmonary bypass(CPB)time(OR=1.01,P<0.001),total arch replacement(TAR,OR=2.40,P=0.02)were independent risk factors for massive bleeding,and the time from onset to operation(OR=0.86,P=0.01)was protective factor.With UDPB 4 class as the end point,multivariate logistic regression showed that creatinine clearance≤85 ml/min(OR=2.05,P=0.001),CPB time(OR=1.01,P=0.04)were independent risk factors for massive bleeding.The time from anset to operation(OR=0.85,P=0.002)and Bentall procedure(OR=0.65,P=0.04)were the protective factors.Conclusion Massive bleeding was more common in acute Stanford type A aortic dissection.Female gender,poor preoperative renal function,high D-dimer level,early time accepting surgical operatio

关 键 词：急性Stanford A型主动脉夹层 出血 全主动脉弓替换 BENTALL手术 

分 类 号：R654.2[医药卫生—外科学]