2019 年第 6 期 第 14 卷

凝血因子Ⅻ及XIII在主动脉夹层围术期凝血功能中的作用研究

Roles of coagulation factor Ⅻ and factor  during perioperative period of aortic dissection surgery

作者：贡鸣李嘉晨关欣亮姜文剑李海洋王晓龙刘愚勇兰峰张宏家

英文作者：

单位：100029首都医科大学附属北京安贞医院心脏外科北京市心肺血管疾病研究所心血管疾病精准医学北京实验室北京市大血管外科植入式人工材料工程技术研究中心

英文单位：

关键词：主动脉夹层；凝血因子Ⅻ；凝血因子；凝血功能障碍；二次开胸

英文关键词：

• 摘要：

• 【摘要】目的    探讨凝血因子Ⅻ及凝血因子XIII在主动脉夹层手术患者围术期的变化及对二次开胸的影响。方法    选取2014年1月至2015年9月于首都医科大学附属北京安贞医院就诊的Stanford A型主动脉夹层患者88例，均接受中度低温停循环手术治疗。根据是否二次开胸将88例患者分为二次开胸组（10例）和未二次开胸组(78例)，比较2组患者手术及术后重要指标，分析凝血功能障碍导致二次开胸的危险因素。选择麻醉诱导后（t1）、术中温度最低点（t2）、复温至36 ℃（t3）、术后4 h（t4）、术后24 h（t5）5个时点进行血液样本的抽取，应用酶联免疫吸附法进行凝血因子Ⅻ、活化的凝血因子Ⅻ、凝血因子Ⅶ、活化的凝血因子Ⅶ、凝血因子XIII、活化的凝血因子XIII、血红蛋白、血小板计数的检测。结果    t2~t4时点凝血因子Ⅻ水平均低于t1，差异均有统计学意义（均P＜0.05），t5时点与t1比较差异无统计学意义（P=0.065）。活化的凝血因子Ⅻ和活化的凝血因子XIII水平由t1~t5全程呈逐渐升高趋势，与t1比较差异均有统计学意义（均P＜0.05）。凝血因子XIII水平各时点均低于t1，差异均有统计学意义（均P＜0.05）。凝血因子Ⅶ水平于t2和t3时点均低于t1， t4和t5时点均高于t1，差异均有统计学意义（均P＜0.05）。二次开胸组术中失血量、术后总引流量以及悬红细胞输注总量、冰冻血浆输注总量、纤维蛋白原输注总量均高于未二次开胸组［1 700(1 375,2 000)ml比 1 250(1 000,1 600)ml；4 250(2 533,7 060)ml比2 170(1 230,3 555)ml；2 700(1 125,3 825)ml比 675(600,1 424)ml；1 200(400,1 550)ml比400(50,800)ml；2.00(2.00,2.88)g比2.00(1.00,2.00)g］，t2时点血小板计数水平低于未二次开胸组［（61±28）×109/L比（72±39）×109/L］，差异有统计学意义（P<0.05）。在校正体质量、体外循环时间、手术时间、低温停循环时间、术前血小板水平、术前血红蛋白水平等因素的影响后，多元Logistic回归分析发现，t2时点凝血因子Ⅻ水平（比值比=1.342，95%置信区间:1.058~1.570，P=0.012）为主动脉夹层患者接受外科手术后凝血功能障碍导致二次开胸的独立危险因素。结论    凝血因子Ⅻ作为内源性凝血途径的启动因子，在主动脉夹层患者围术期的凝血功能中发挥着巨大作用，其在术中最低温时的水平较低可能是术后由于凝血功能障碍导致二次开胸的独立危险因素；而凝血因子XIII作为凝血共同途径的重要因子，本研究未发现其增加二次开胸的风险。

• 【Abstract】Objective    To explore the changes of coagulation factor Ⅻ and factor XIII during perioperative period of aortic dissection surgery and the effect on secondary thoracotomy. Methods    Eighty-eight patients with Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest surgery in Beijing Anzhen Hospital, Capital Medical University were enrolled from January 2014 to September 2015; the patients were divided into secondary thoracotomy group（10 cases） and non-secondary thoracotomy group（78 cases）. Coagulation factor Ⅻ and activated factor Ⅻ, factor Ⅶ and activated factor Ⅶ, factor XIII and activated factor XIII, hemoglobin and platelet count were detected after anesthesia induction（t1）, at the lowest temperature（t2） and after recovery to 36 ℃（t3） during circulatory arrest, 4 h（t4） and 24 h（t5） after surgery. Relevant factors of secondary thoracotomy due to coagulation disorder were analyzed. Results    Coagulation factor Ⅻ significantly decreased during t2-t4 compared to that at t1(P<0.001) and recovered to the initial level at t5（P=0.065）. Activated factor Ⅻ and activated factor XIII significantly increased during t1-t5（P＜0.05）. Coagulation factor XIII significantly decreased during t2-t5（P＜0.05）. Coagulation factor Ⅶ significantly decreased at t2, t3 and increased at t4, t5（all P＜0.05）. Intraoperative blood loss, postoperative drainage volume, transfusion volumes of suspended red blood cells, refrigerated plasma and fibrinogen in secondary thoracotomy group were significantly higher than those in non-secondary thoracotomy group［1 700(1 375,2 000)ml vs 1 250(1 000,1 600)ml; 4 250(2 533,7 060)ml vs 2 170(1 230,3 555)ml; 2 700(1 125,3 825)ml vs 675(600,1 424)ml; 1 200(400,1 550)ml vs 400(50,800)ml; 2.00(2.00,2.88)g vs 2.00(1.00,2.00)g］; platelet count at t2 in secondary thoracotomy group was significantly lower than that in non-secondary thoracotomy group［（61±28）×109/L vs （72±39）×109/L］（all P<0.05）. With adjustments of body mass, cardiopulmonary bypass time, operation time, circulatory arrest time, preoperative platelet and hemoglobin levels, multivariable logistic regression analysis suggested that coagulation factor Ⅻ level at t2 was an independent risk factor of reoperation due to coagulation disorder（odds ratio=1.342, 95% confidence interval: 1.058-1.570, P=0.012）. Conclusions    As the initiator of intrinsic pathway, coagulation factor Ⅻ plays an important role during the perioperative period of aortic dissection surgery; the level of factor Ⅻ during hypothermic circulatory arrest may be an independent risk factor of reoperation due to coagulopathy. Coagulation factor XIII is an important element in the common coagulation pathway and partly regulates the function of fibrinogen by a feedback mechanism.