720例机械瓣膜置换术围手术期并发症相关危险因素分析

发布时间：2018-07-14 17:25

【摘要】：[目的]心瓣膜病(valvular heart disease,VHD)仍然是临床和公共健康的负担。对于发展中国家来说,风湿热仍然是导致心瓣膜病主要发病原因。在我国,成人风湿性心瓣膜病的发病率为2.34‰～2.72‰。心瓣膜病的治疗分为内科治疗和外科治疗,其中外科治疗方法是瓣膜疾病唯一有效能够明显改善患者症状及预后的方法。在云南地区,外科治疗心瓣膜病的方法主要是人工机械瓣膜置换术。虽然经过了接近半个世纪的发展,心脏手术在体外循环(Cardiopulmpnary Bypass CPB)的支持下已经非常成熟,但毋庸置疑的是它仍然是一个非常复杂且特殊的手术,术前患者生理状态、手术时长、围手术期的各种侵入性操作、体外循环、机械异物的植入等共同构成了围术期的高危因素,忽略它们将带来致命的后果。本次研究统计在我科行单纯人工机械瓣膜置换术的患者的术前及术中资料及在围术期发生的各类并发症,分析导致并发症的相关危险因素,采取相应预防措施,为减少及预防云南地区心脏瓣膜置换术围手术期的并发症提供一定的参考依据。[方法]根据国内外文献及相关风险模型的纳入标准,筛选出2011年1月1日至2013年3月1日期间在延安医院心脏大血管外科接受人工机械瓣膜换瓣手术的患者,共720例,纳入的潜在危险因素有如下:年龄、性别、病程、房颤、心功能分级、高血压史、糖尿病史、肝肾功能、心脏射血分数(EF值)、左室舒张末容积(LVEDV)、左房舒张末期容积(LAEDV)、手术方式、疾病种类、转流时间、阻断时间。统计的围术期并发症有:低心排综合症、室颤(Ventricular FibrillationVF)、心律紊乱、肾功能衰竭、肝功能衰竭、MODS、脑梗、低氧血症、心跳骤停、循环不稳定、心包填塞、心包积液、胸腔积液、肺部炎性渗出。统计学方法采用方差分析,卡方检验先筛查出相关联的潜在危险因素,再用Logistic单因素和多因素拟合回归模型,利用SPSS 22统计分析软件尝试找出潜在危险因素和相关并发症之间的联系。[结果]720例患者中总的并发症人数为220人;其中低心排综合征为31例(10.8%)、室颤2例(0.7%)、心律紊乱47例(16.7%)、急性肾衰竭7例(2.4%)、肝衰2例(0.7%)、MODS 5例(1.7%)、脑梗6例(2.1%)、低氧血症4例(1.4%)、心跳骤停2例(0.7%)、循环不稳定15例(5.2%)、心包填塞2例(0.7%)、心包积液75例(26.1%)、胸腔积液14例(4.9%)、瓣周漏1例(0.3%)、肺部炎性渗出74例(25.8%);死亡6人。Logistic单因素分析结果为年龄、性别、糖尿病史、术前房颤、风湿性心脏瓣膜病、退行性二尖瓣病变、手术方式分别是围术期心跳骤停、急性肾衰竭、循环不稳定、心律紊乱、低氧血症、室颤的独立危险因素(P0.05);病程时间长是围术期低氧血症、肾衰、胸腔积液的独立危险因素(P0.05);感染性心内膜炎是围术期出现MODS、肝功能障碍、肾衰竭的独立危险因素(P0.05);LVEDV是围术期出现低心排综合征、MODS、心律紊乱的独立危险因素(P0.05) ; LAEDV是出现肾衰、循环不稳、心包积液(10mm)的独立危险因素(P0.05);转流时间是围术期出现低心排综合征、肾衰、循环不稳定、心包填塞、心包积液的独立危险因素(P0.05);阻断时间是出现低心排综合征、循环不稳定、心包积液、胸腔积液、心包填塞的独立危险因素(P0.05) ; Logistic多因素回归模型分析显示:EF值、LVEDV、转流时间、阻断时间共同为围术期出现低心排综合征的危险因素(P0.05);性别、病程、肌酐值、LAEDV、转流时间、阻断时间是围术期发生急性肾功衰的危险因素(P0.05);术前肌酐值、LVEDV、主动脉瓣置换术是围术期发生MODS的危险因素(P0.05);转流时间和阻断时间是围术期发生脑梗的的危险因素(P0.05);术前糖尿病史、LAEDV、转流时间、阻断时间是围术期发生循环不稳定的的危险因素(P0.05)。[结论]本次研究发现心脏瓣膜手术的治疗效果和患者病史、各重要器官功能状态、心脏病理改变、手术的方式、体外循环时间、围术期处理等多种因素密切相关,围术期各种并发症的出现是一个复杂的生理病理过程。手术前谨慎选择手术患者,制定安全有效的手术措施、术中、术后予相应有效地治疗措施一定能有效降低心脏换瓣术后围术期患者的并发症发生率。
[Abstract]:[Objective] valvular heart disease (VHD) is still a burden of clinical and public health. For developing countries, rheumatic fever is still the main cause of heart valvular disease. In China, the incidence of rheumatic valvular disease in adults is 2.34 to 2.72 per thousand. The treatment of heart valvular disease is divided into internal medicine treatment and surgical treatment. Surgical treatment is the only effective way to improve the symptoms and prognosis of patients with valvular disease. In Yunnan, surgical treatment of valvular heart valve disease is mainly by prosthetic valve replacement. Although after nearly half a century of development, cardiac surgery has been supported by Cardiopulmpnary Bypass CPB in vitro. It is very mature, but it is unquestionable that it is still a very complex and special operation. The physiological state of the patients, the length of the operation, the various invasive operations in the perioperative period, the extracorporeal circulation, the implantation of the mechanical foreign body together constitute the high risk factors of the perioperative period, ignoring the fatal consequences. This study statistics is in our department. The preoperative and intraoperative data of patients with simple mechanical valve replacement and the various complications during the perioperative period, analyze the related risk factors leading to the complications and take corresponding preventive measures to provide some reference for reducing and preventing the perioperative complication of heart valve replacement in Yunnan. The inclusion criteria of internal and external literature and related risk models were used to screen 720 patients undergoing cardiac valve replacement surgery at Yanan hospital from January 1, 2011 to March 1, 2013. The potential risk factors included age, sex, disease course, atrial fibrillation, cardiac function classification, hypertension history, diabetes history, liver Renal function, cardiac ejection fraction (EF), left ventricular end diastolic volume (LVEDV), left atrium end diastolic volume (LAEDV), surgical methods, disease types, bypass time, blocking time. The perioperative complications were low cardiac syndrome, ventricular fibrillation (Ventricular FibrillationVF), arrhythmia, renal failure, liver failure, MODS, cerebral infarction, hypoxia. Anemia, cardiac arrest, circulatory instability, pericardial filling, pericardial effusion, pleural effusion, pulmonary inflammatory exudation. Statistical methods were analyzed by variance analysis. The associated potential risk factors were screened by chi square test, and Logistic single factor and multiple factor fitting regression model were used, and SPSS 22 statistical analysis software was used to try to find potential risk factors. [results] the total number of complications in]720 patients was 220, including 31 cases of low cardiac syndrome (10.8%), 2 cases of ventricular fibrillation (0.7%), 47 cases of arrhythmia (16.7%), 7 cases of acute renal failure (2.4%), 2 cases of liver failure (0.7%), 5 cases (1.7%), cerebral infarction, hypoxemia, cardiac arrest, and circulation. 15 cases were unstable (5.2%), pericardial filling in 2 cases (0.7%), pericardial effusion in 75 cases (26.1%), pleural effusion in 14 cases (4.9%), pericardial leakage in 1 cases (0.3%), pulmonary inflammatory exudation in 74 cases (25.8%); death 6.Logistic single factor analysis results were age, sex, diabetes history, anterior chamber fibrillation, rheumatic valvular heart valvular disease, and degenerative mitral valve disease. The surgical methods were respectively operation methods, respectively. Perioperative cardiac arrest, acute renal failure, circulatory instability, arrhythmia, hypoxemia, independent risk factors for ventricular fibrillation (P0.05); long course time is an independent risk factor for perioperative hypoxemia, renal failure, and pleural effusion (P0.05); infectious endocarditis is an independent risk factor for the emergence of MODS, liver dysfunction and renal failure during the perioperative period (P0.05 LVEDV is an independent risk factor (P0.05) with low cardiac output syndrome, MODS and arrhythmia in the perioperative period; LAEDV is an independent risk factor (P0.05) of renal failure, circulatory instability and pericardial effusion (10mm); the time of bypass is an independent risk factor (P0.05) in the perioperative period of low cardiac syndrome, renal failure, circulatory instability, pericardial filling, and pericardial effusion. Blocking time was an independent risk factor for the emergence of low cardiac output syndrome, circulatory instability, pericardial effusion, pleural effusion, and pericardial tamponade (P0.05); Logistic multiple regression model analysis showed that EF, LVEDV, bypass time and blocking time were the risk factors for low cardiac output syndrome (P0.05) in peri operative period; sex, course of disease, creatinine, LAEDV, Time and interruption time were risk factors for acute renal failure during perioperative period (P0.05); preoperative creatinine value, LVEDV, aortic valve replacement were risk factors for MODS in the perioperative period (P0.05); time and blocking time were the risk factors of cerebral infarction (P0.05) in perioperative period; preoperative diabetes history, LAEDV, bypass time, blocking time The risk factors of circulatory instability during the perioperative period (P0.05). [Conclusion] this study found that the therapeutic effect of cardiac valve surgery, the history of the patients, the function state of the important organs, the pathological changes of the heart, the mode of operation, the time of extracorporeal circulation, the treatment of perioperative period are closely related, and the occurrence of various complications in the perioperative period is one Complex physiological and pathological processes. Careful selection of surgical patients before operation, safe and effective surgical measures, and appropriate effective treatment in the operation and after operation are sure to effectively reduce the incidence of complications in the perioperative patients after heart valve replacement.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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