心肌停搏液灌注方式与急性Stanford A型主动脉夹层术后新发房颤的相关性

Correlation between the myocardial protection solution infusion strategies and the new-onset postoperative atrial fibrillation after acute Stanford type A aortic dissection surgery

摘要

目的 探讨心肌停搏液灌注方式与急性Stanford A型主动脉夹层(acute Stanford type A aortic dissection, AAAD)术后新发房颤的相关性,旨在减少AAAD术后房颤的发生率。 方法 回顾性分析2020年1月1日至2024年12月31日南京大学医学院附属鼓楼医院确诊为AAAD患者207例,按照术中心肌停搏液灌注方式分为顺行灌注组(n=121)和逆行灌注组(n=86)。主要终点事件为术后7 d内新发房颤,次要终点事件为呼吸机机械通气时间和ICU住院时间。采用多因素logistic回归分析心肌停搏液灌注方式与术后新发房颤之间的相关性,并采用3种倾向评分进行校正以控制组间混杂因素;对不同手术方式进行亚组分析,并开展治疗获益人数分析。采用多因素logistic回归分析探讨AAAD术后新发房颤的独立危险因素。 结果 AAAD术后新发房颤发生率为38.65%(80/207),两组差异无统计学意义(39.67% vs. 37.21%,P=0.831)。次要终点方面,两组呼吸机机械通气时间差异无统计学意义(27.00 h vs. 21.50 h,P=0.075);但顺行灌注组的ICU住院时间短于逆行灌注组,差异有统计学意义(128.00 h vs. 160.50 h,P=0.012)。多因素logistic回归分析及3种倾向评分校正分析均未显示心肌停搏液灌注方式与术后新发房颤之间呈相关性(P>0.05)。不同手术方式亚组分析也未发现不同灌注方式对术后新发房颤有影响;治疗获益人数分析也未发现不同灌注方式对术后新发房颤带来临床获益(治疗获益人数:40,95%CI:-9~6);此外,多因素logistic回归分析提示,高龄(OR=1.08,95%CI:1.03~1.14,P=0.003)、冠心病史(OR=2.45,95%CI:1.28~4.69,P=0.007)、更长的手术时间(OR=1.02,95%CI:1.01~1.04,P=0.032)和更长的ICU住院时间(OR=1.15,95%CI:1.06~1.25,P=0.011)是AAAD术后新发房颤的独立危险因素。 结论 在AAAD患者中,心肌停搏液灌注方式与术后新发房颤无相关性,顺行灌注可作为常规策略;但高龄、合并冠心病以及手术和ICU住院时间延长是AAAD术后新发房颤的独立危险因素,灌注方式仍需个体化选择。

Abstract

Objective To investigate the correlation between myocardial protection solution infusion strategies and the occurrence of new-onset postoperative atrial fibrillation in patients with acute Stanford type A aortic dissection(AAAD), with the aim of reducing the incidence of atrial fibrillation. Methods This retrospective study included 207 patients diagnosed with AAAD at Drum Tower Hospital from January 1, 2020, to December 31, 2024. Patients were categorized into an antegrade cardioplegia group(n=121)and a retrograde cardioplegia group(n=86)based on the myocardial protection solution infusion strategy. The primary endpoint was the incidence of new-onset atrial fibrillation, and secondary endpoints included mechanical ventilation duration and Intensive Care Unit(ICU)stay. Multivariate logistic regression analysis was used to assess the correlation between myocardial protection solution infusion strategy and new-onset atrial fibrillation, and three propensity score methods were used for adjustment. Subgroup analyses were conducted on different surgical methods, and the number needed to treat was analyzed. In addition, multivariate logistic regression analysis was used to explore the independent risk factors for new-onset atrial fibrillation after AAAD. Results The overall incidence of atrial fibrillation was 38.65%, showing no significant statistical difference between the two groups(39.67% vs. 37.21%, P=0.831). Regarding secondary endpoints, there was no statistically significant difference in the duration of mechanical ventilation on a ventilator between the antegrade perfusion group and the retrograde perfusion group(27.00 h vs. 21.50 h, P=0.075). However, the ICU stay in the antegrade perfusion group was shorter than that in the retrograde perfusion group, and the different was statistically significant(128.00 h vs. 160.50 h, P=0.012). Multivariate logistic regression and propensity score adjustment analyses also did not show a significant correlation between myocardial protection solution infusion methods and the incidence of new-onset atrial fibrillation(P>0.05). Subgroup analysis revealed no significant difference in atrial fibrillation occurrence between the two infusion methods. The analysis of the number of patients benefiting from treatment also did not find that different perfusion methods brought clinical benefits to the new-onset atrial fibrillation after surgery( number needed to treat: 40, 95%CI: -9-6). In addition, multivariate logistic regression analysis showed that advanced age(OR=1.08,95%CI:1.03-1.14,P=0.003), suffering from coronary heart disease(OR=2.45,95%CI:1.28-4.69,P=0.007), longer operation time(OR=1.02,95%CI:1.01-1.04,P=0.032)and longer ICU stay(OR=1.15,95%CI:1.06-1.25,P=0.011)were independent risk factors for new-onset atrial fibrillation after AAAD surgery. Conclusion In patients with AAAD, there is no significant correlation between myocardial protection solution infusion strategy and the incidence of new-onset atrial fibrillation. Antegrade cardioplegia can be recommended as the standard strategy. However, given that advanced age, comorbid coronary artery disease, prolonged operative duration, and extended ICU stay are independent risk factors, the choice of cardioplegia strategy should still be individualized.

关键词

急性Stanford A型主动脉夹层 / 术后新发房颤 / 心脏外科手术 / 心肌保护 / 心肌停搏液

Key words

Acute stanford type A aortic dissection / New-onset atrial fibrillation / Cardiothoracic surgery / Myocardial protection strategies / Myocardial cardioplegia

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基金资助

国家自然科学基金青年项目(82300312)

国家自然科学基金面上项目(82270346)