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左心室射血分数的多因素分析

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目的 探讨如何筛选出血运重建后左心室射血分数(LVEF)明显增加的缺血性心肌病(ischaemic cardiomyopathy,ICM)患者。 方法 回顾性分析我院 2010 年 7 月至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%),其中合并缺血性二尖瓣反流 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差异无统计学意义(P=0.199)。A 组患者的左心室舒张期末内径(LVEDD)、左心室收缩期末内径(LVESD)、左室舒张期末容积(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 为 41~71 mm ,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%CI 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 We probed how to predict left ventricular ejection fraction (LVEF) of the ischaemic cardiomyopathy (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 patients 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 were 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 by 10%: a LVEF recovered group (group A, 124 patients) and a non-recovered group (group B, 108 patients). Results Preoperative NT-proBNP in the group A was significantly higher than that in the group B (P=0.036). There were less patients with myocardial infarction in the group A than that in the group B (P=0.047), and more with angina pectoris in the group A than that in the group B (P=0.024). There was no significant difference in the extent of mitral regurgitation or mitral surgery between the 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 the group A than those in the group B (P<0.05). Multivariate analysis revealed that preoperative LVEDD dilated apparently and no angina pectoris existed before surgery were independent risk factors for LVEF with no recovery in the ICM patients (30%≤LVEF≤40%) after revascularization. The LVEDD of 245 patients (including 13 early deaths) was 41-71 mm. We found 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 to 3.91). Conclusion Preoperative LVEDD dilated and no angina pectoris before surgery are independent risk factors for LVEF with no recovery in the ICM patients (30%≤LVEF≤40%) after revascularization. LVEDD≥60 mm can be regarded as the preoperative forecasting factors for the unfavourable prognosis in the 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; 左室舒张期末内径

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

引用本文: 金岩, 王辉山, 姜辉, 陶登顺, 赵科研, 于岩, 赵洋. 影响缺血性心肌病血运重建后左心室射血分数的多因素分析. 中国胸心血管外科临床杂志, 2018, 25(12): 1043-1048. doi: 10.7507/1007-4848.201801065 复制

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