2023 年第 9 期 第 18 卷

术前合并脏器灌注不良对A型主动脉夹层手术早期预后的影响

Effect of preoperative organ malperfusion on the early prognosis of type A aortic dissection surgery

作者：乔志钰陈苏伟张宸翰葛翼鹏胡海瓯齐瑞东里程楠刘永民朱俊明

英文作者：Qiao Zhiyu Chen Suwei Zhang Chenhan Ge Yipeng Hu Haiou Qi Ruidong Li Chengnan Liu Yongmin Zhu Junming

单位：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，北京100029

英文单位：Department of Cardiac Surgery Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 100029 China

关键词：A型主动脉夹层；脏器灌注不良；主动脉修复；主要不良事件

英文关键词：TypeAaorticdissection;Organmalperfusion;Aorticrepair;Mainadverseevents

• 摘要：

• 目的  分析术前合并脏器灌注不良（OMP）对A型主动脉夹层(TAAD)手术早期预后的影响。方法 收集2019年1月至2020年1月因TAAD于首都医科大学附属北京安贞医院接受手术治疗的405例患者的围手术期临床资料进行回顾性分析。按照是否合并术前OMP分为OMP组（140例）和无OMP组（265例）。比较2组一般资料和围手术期结果，分析术后死亡及主要不良事件（MAE）的危险因素。结果 OMP组体外循环时间明显长于无OMP组，接受全主动脉弓置换联合支架象鼻植入术和下肢动脉转流术比例高于无OMP组［197(173, 221)min比185(154,214)min、85.0%（119/140）比74.0%（196/265）、8.6%（12/140）比0.4%（1/265）］（均P<0.05)。2组手术死亡率差异无统计学意义（P>0.05），但OMP组的MAE发生率明显高于无OMP组［44.3%（62/140）比24.2%（64/265）］（P<0.001)。此外，OMP组术后机械通气时间和重症监护病房滞留时间明显长于无OMP组，术后急性肾损伤、脑卒中及脊髓损伤的发生率明显高于无OMP组(均P<0.05)。多因素Logistic回归分析发现，OMP个数≥2是TAAD患者术后死亡的独立危险因素(比值比=3.989，95%置信区间：1.307～12.176，P=0.015)。女性、体外循环时间>180 min和OMP是发生MAE的独立危险因素，而且随着OMP个数的增加MAE事件的发生风险增加(均P<0.05)。结论 合并OMP的TAAD患者术中需要更长的体外循环时间、接受更高比例的主动脉弓部修复及下肢转流术，术后发生肾脏及神经系统并发症的比例更高。同时，OMP还延长了患者术后机械通气时间和重症监护病房滞留时间。虽然OMP不增加TAAD患者手术死亡率，但增加了MAE发生率。而且，随着OMP累及数量的增加，MAE的发生风险增加。

• Objective To analyze the effect of preoperative organ malperfusion(OMP) on the early prognosis of type A aortic dissection(TAAD) surgery. Methods The perioperative clinical data of 405 patients who received surgical treatment for TAAD in Beijing Anzhen Hospital, Capital Medical University from January 2019 to January 2020 were collected for retrospective analysis. They were divided into OMP group(140 cases) and non OMP group(265 cases) based on whether preoperative OMP was combined or not. The general data and perioperative results  were compared between the two groups, and the risk factors for postoperative death and major adverse events(MAE) were analyzed. Results The cardiopulmonary bypass time in OMP group was significantly longer than that in non OMP group, and the proportions of patients receiving total aortic arch replacement combined with stent elephant trunk implantation and lower limb artery bypass were higher than those in non OMP group ［197(173,221)min vs 185(154,214)min, 85.0%(119/140) vs 74.0%(196/265), 8.6%(12/140) vs 0.4%(1/265)］(all P<0.05). There was no statistically significant difference in surgical mortality between the two groups(P>0.05), but the incidence of MAE in the OMP group was significantly higher than that in the non OMP group［44.3%(62/140) vs 24.2%(64/265)］(P<0.001). In addition, the postoperative mechanical ventilation time and intensive care unit stay time in the OMP group were significantly longer than those in the non OMP group, the incidences of postoperative acute kidney injury, stroke and spinal cord injury were significantly higher than those in the non OMP group(all P<0.05). Multivariate Logistic regression analysis showed that number of OMP≥2 was an independent risk factor for postoperative mortality in TAAD patients(odds ratio=3.989, 95% confidence interval: 1.307-12.176, P=0.015). Women, cardiopulmonary bypass time>180 min, and OMP were independent risk factors for MAE, and the risk of MAE events increases with the number of OMP (all P<0.05). Conclusions  sTAAD patients with OMP required longer cardiopulmonary bypass time, and received a higher proportion of aortic arch repair and lower extremity bypass. The rates of renal and neurological complications are higher. OMP also extended the mechanical ventilation time and intensive care unit stay time. Although OMP did not increase operative mortality in patients with TAAD, it increased the incidence of MAE. Moreover, the risk of MAE increases with the increase in the number of OMP involvement.