中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

影响缺血性心肌病血运重建后 LVEF 的多因素分析

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目的 血运重建后左室射血分数(LVEF)能明显改善的缺血性心肌病(ischaemic cardiomyopathy,ICM)患者,其生活质量和预期寿命明显提高。本研究探讨如何筛选出血运重建后 LVEF 明显增加的 ICM 患者。 方法 回顾性分析了我院 2010 年 7 月~2015 年 12 月期间,245 例行冠状动脉旁路移植术(coronary bypass grafting,CABG)(30%≤LVEF≤40%),其中伴有缺血性二尖瓣反流 146 例(146/245,59.6%),有 41 例患者因中度以上的缺血性二尖瓣反流而同时行二尖瓣成形术/置换术。围术期死亡 13 例(12 例为 CABG+二尖瓣成形术或置换术,1 例为单纯行 CABG 术),余 232 例随访 6 个月以上为研究对象,根据术后 LVEF 是否增加 10% 分为两组,即 LVEF 恢复组(A 组)124 例,LVEF 不恢复组(B 组)108 例。 结果 单因素分析发现 A 组术前 NT-proBNP 值明显高于 B 组(P=0.036),有心肌梗死病史的比例明显低于 B 组(P=0.047),而术前仍有心绞痛的比例明显高于 B 组(P=0.024)。两组之间的二尖瓣反流程度及二尖瓣成形术或置换术比例无明显差异(P=0.199)。A 组患者的左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)、左室舒张末期容积(LVEDV)均明显低于 B 组(P<0.05)。多因素分析发现 LVEDD 明显增大、术前无明显心绞痛是 ICM(30%≤LVEF≤40%)患者行血运重建后 LVEF 不能恢复的术前危险因素。以 245 例患者(包括 13 例围术期死亡患者)为研究对象,其 LVEDD 在 41 mm~71 mm 之间,发现 LVEDD≥60 mm 与 ICM 患者的预后不良有显著关系,χ2=8.63,P=0.003,OR=2.21,95% 可信区间为 1.25~3.91。 结论 发现 LVEDD 明显增大、术前无明显心绞痛是 ICM(30%≤LVEF≤40%)患者行血运重建后 LVEF 不能恢复的术前危险因素。LVEDD≥60 mm 可以作为 ICM(30%≤LVEF≤40%)患者预后不良的术前临床筛选指标之一。

Objective The quality and expectancy of life in patients with ischaemic cardiomyopathy (ICM) would be improved apparently, if left ventricular ejection fraction (LVEF) after revascularization were significantly improved. We probe how to predict LVEF of the ICM patients would be improved apparently after revascularization. Methods Between July 2010 and December 2015, 245 ICM patients (30%≤LVEF≤40%) with coronary bypass grafting (CABG) were retrospectively observed. Among them, 146 cases were accompanied by ischemic mitral regurgitation (IMR) (146/245, 59.6%), and 41 patients underwent mitral valvuloplasty or replacement because of more than moderate IMR. There are 13 patients early death, and other 232 patients who were followed up over 6 months were divided into two groups based on whether or not post-operative LVEF increased 10%: LVEF recovered groups (124 patients) and non-recovered group (108 cases). Results Preoperative NT-proBNP in Group A had significantly higher than that in Group B (P=0.036). There were less patients with myocardial infarction in Group A than in Group B (P=0.047), and more with angina pectoris in Group A than in Group B (P=0.024). There were no significant differences in the extent of mitral regurgitation and mitral surgery between Groups A and B (P>0.05). There were lower left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD) and left ventricular end-diastolic volume (LVEDV) in Group A than in Group B (P<0.05). Multivariate analysis revealed that dilated apparently in preoperative LVEDD and no angina pectoris existed before surgery were independent risk factors for LVEF no recovered in ICM patients (30%≤LVEF≤40%) after revascularization. If 245 patients were observed, including 13 patients early death, whose LVEDD were between 41 mm and 71 mm, we proposed that the ICM patients with LVEDD ≥60 mm were more likely to signify the unfavourable prognosis,χ2=8.63, P=0.003, OR=2.21, 95% confidence interval 1.25–3.91. Conclusions Proposed that dilated apparently in preoperative LVEDD and no angina pectoris existed before surgery were independent risk factors for LVEF no recovered in ICM patients (30%≤LVEF≤40%) after revascularization. LVEDD≥60 mm could be regarded as the preoperative forecasting factors for the unfavourable prognosis in ICM patients (30%≤LVEF≤40%) after revascularization.

关键词: 缺血性心肌病; 冠状动脉旁路移植术; 左室射血分数; 左室舒张末期内径

Key words: Ischaemic cardiomyopathy; coronary bypass grafting; left ventricular ejection fraction; left ventricular end-diastolic diameter

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