二尖瓣位人工瓣膜—患者不匹配现象的单中心回顾性研究

发布时间：2019-01-15 07:09

【摘要】：目的本研究拟探究我中心二尖瓣置换术后患者人工瓣膜-患者不匹配(PPM)现象的发生概率,分析该现象发生的可能危险因素,并探究其对患者短期预后的影响。从而为术中预防人工瓣膜-患者不匹配现象的发生提供临床依据,为临床处理、应对该现象提供参考。方法本研究采用回顾性研究的方法,纳入2013年-2015年于我中心行单纯或合并二尖瓣置换术的所有患者资料,经筛选和排除后,共纳入1067例患者资料进行分析。利用患者使用人工瓣膜的有效开口面积及患者体表面积计算患者的有效开口面积指数,并根据该指数将患者分为人工瓣膜不匹配组(PPM组,共189例)及非不匹配组(非PPM组,共878例)。比较两组患者的一般信息、临床表现、既往病史、术前检查结果、术中信息及术后并发症发生情况等资料。通过逻辑回归,分析人工瓣膜不匹配现象发生的术前预测因子,并分析不匹配现象对于患者术后短期死亡率的影响。结果共计1067例患者资料纳入研究,其中人工瓣膜不匹配现象的发生率为17.7%,其中重度PPM的发生率为1.12%。在术前临床资料方面,PPM组在平均年龄(63 vs54,P0.001)、男性比例(35.5%vs47.1%,P0.001)、体表面积(1.64±0.17m~2 vs 1.55 ± 0.16m~2,P0.001)、BMI(23.34 ± 2.86kg/m~2 vs 22.07 ± 3.79 kg/m~2,P0.001)、吸烟史比例(16.9%vs 10.4%,P=0.016)、高血压(24.9%vs 16.5%,P=0.009)及冠心病(4.8%vs1.5%,P=0.009)发生率方面高于非PPM组。而在置换生物瓣患者中,PPM组术前二尖瓣狭窄比例显著高于非PPM组(58.3%vs 41.7%,P=0.019)。两组患者在其他既往病史、房颤、术前心功能、左室射血分数、左室舒张末期内径、左房内径、急诊手术比例等方面无显著差异。在手术资料方面,PPM组生物瓣置换(50.8%vs 11.7%,,P0.001)比例显著高于非PPM组,搭桥(5.8%vs1.9%,P=0.005)及房颤(15.9%vs 8.7%,P=0.005)合并手术比例相对较高。二元逻辑回归分析表明高龄(P=0.011)、大体表面积(P0.001)、生物瓣(P0.001)和小左室舒张末期内径(P0.001)是PPM发生的术前危险因素。两组患者在术后并发症情况方面无明显差异,术后短期共9名患者死亡,死亡率为0.84%,逻辑回归分析表明PPM并不是术后短期死亡的影响因素(P=0.654)。随访结果表明,PPM组及非PPM组随访心功能Ⅲ-Ⅳ级均为9%左右,在中短期心功能方面无明显差异(9.6%vs9.0%,P=0.902)。结论本研究表明,高龄、生物瓣置换、体表面积及左室舒张末期内径同二尖瓣位PPM发生有显著关联,但二尖瓣位PPM对二尖瓣置换术后中短期预后无明显影响。我国华东地区患者,二尖瓣狭窄比例较高,因此PPM标准是否适用于该地区患者仍有待进一步探究。
[Abstract]:Objective to investigate the probability of (PPM) mismatch in patients with mitral valve replacement, to analyze the possible risk factors of this phenomenon and to explore its influence on the short-term prognosis of the patients with mitral valve replacement. It can provide clinical basis for prevention of prosthetic valvular mismatch during operation and provide reference for clinical treatment. Methods the data of all patients undergoing mitral valve replacement or simple mitral valve replacement from 2013 to 2015 were analyzed by retrospective study. After screening and exclusion, 1067 patients were analyzed. The effective opening area index of patients was calculated by using the effective opening area of prosthetic valve and the surface area of patients. According to the index, patients were divided into two groups: PPM group (n = 189) and non-matched group (non-PPM group). There were 878 cases. The general information, clinical manifestation, past medical history, preoperative examination results, intraoperative information and postoperative complications were compared between the two groups. By means of logical regression, the factors that predict the occurrence of prosthetic valve mismatch were analyzed, and the influence of mismatch on short-term mortality after operation was analyzed. Results A total of 1067 patients were included in the study. The incidence of prosthetic valve mismatch was 17. 7 and the incidence of severe PPM was 1. 12. In the preoperative clinical data, the average age (63 vs54,P0.001), male ratio (35.5vs47.1%), body surface area (1.64 卤0.17m~2 vs 1.55 卤0.16 mm2 P0.001) in PPM group were significantly higher than those in control group (P 0.001). BMI (23.34 卤2.86kg/m~2 vs 22.07 卤3.79 kg/m~2,P0.001), proportion of smoking history (16.9%vs 10.4), 24.9%vs (16.5 kg/m~2,P0.001), The incidence of coronary heart disease (P0. 009) and coronary heart disease (4. 8 vs 1. 5% P0. 009) was higher than that in non-PPM group. The mitral stenosis rate in PPM group was significantly higher than that in non PPM group (58.3%vs 41.7). There was no significant difference between the two groups in other medical history, atrial fibrillation, preoperative cardiac function, left ventricular ejection fraction, left ventricular end-diastolic diameter, left atrial diameter and the proportion of emergency surgery. In terms of surgical data, the ratio of 50.8%vs 11.7T / P0.001 in PPM group was significantly higher than that in non-PPM group, and the ratio of bypass graft (5.8 vs 1.9) and atrial fibrillation (15.9%vs 8.7) was significantly higher than that in non-PPM group. P0. 005) the ratio of combined operation was relatively high. Binary logistic regression analysis showed that old age (P0. 011), large body surface area (P0. 001), biological flap (P0. 001) and left ventricular end diastolic diameter (P0. 001) were the risk factors of PPM. There was no significant difference in postoperative complications between the two groups. Nine patients died and the mortality rate was 0.84.The logistic regression analysis showed that PPM was not the influencing factor of short-term postoperative mortality (P0. 654). The follow-up results showed that the heart function of PPM group and non-PPM group were about 9%, and there was no significant difference in heart function between middle and short term (9.6vs9.00.902). Conclusion there is a significant correlation between PPM in mitral valve position and advanced age, biological valve replacement, surface area and left ventricular end-diastolic diameter, but mitral valve PPM has no significant effect on the short and medium term prognosis of mitral valve replacement. The mitral stenosis ratio is high in East China, so whether the PPM standard can be applied to the patients in this area remains to be further explored.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R654.2

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