Knayzer Boris, Abramov Dan, Natalia Bilenko, Tovbin David, Ganiel Amir, Katz Amos
Department of Cardiothoracic Surgery, Soroka Medical Center, Beer-Sheva, Israel.
J Card Surg. 2007 Mar-Apr;22(2):117-23. doi: 10.1111/j.1540-8191.2006.00366.x.
Recent studies have demonstrated correlation between inflammation to plasma troponin (cTnI) levels elevation and atrial fibrillation (AF) in noncardiac surgery settings. The goal of this prospective study was to examine the relation between inflammation associated parameters (IAPs) to post cardiac surgery cTnI elevation and AF.
A single post CABG cTnI measurement was assessed in 156 consecutive patients. Clinical, operative and postoperative data, IAPs (hypophosphatemia, preoperative statin treatment, immediate postoperative fever, and prolonged mechanical ventilation) and in-hospital AF episodes were prospectively recorded.
Mean cTnI level was 14.4 +/- 12.4 ng/mL. In the two in-hospital deaths (1.2%) cTnI concentration was less than 12 ng/mL. Cardiac troponin-I levels were significantly higher in patients not preoperatively treated with statins (21.6 +/- 4.1 vs. 13.3 +/- 0.9, p = 0.05), in patients who needed intraoperative cardioversion (16.7 +/- 2.2 vs. 12.2 +/- 0.9, p = 0.07), in patients with postoperative hypophosphatemia (16.9 +/- 10.0 vs. 11.1 +/- 13.7, p = 0.04), postoperative fever (18.6 +/- 3.0 vs. 13.7 +/- 1.0, p = 0.07) and postoperative respiratory complications (23.9 +/- 4.3 vs. 13.5 +/- 1.0, p = 0.04). Step-wise logistic regression analysis revealed the following parameters as independently associated with elevated cTnI levels: preoperative statin treatment (CI 95%-15.9; -1.7, p = 0.02), intraoperative ventricular arrhythmia (CI 95%-0.7; 13.8, p = 0.08), hypophosphatemia (CI 95% 0.9; 8.6, p = 0.02), postoperative fever (CI 95% 0.9; 11.0, p = 0.02), and postoperative respiratory complications (CI 95% 0.1; 0.5, p = 0.01). Of the 156 patients, 50 (32.1%) had postoperative AF. The first episode of AF occurred between postoperative day 1 and 6 (mean-day 2). Mean duration of AF was 21.8 +/- 8.1 hours. Postoperative AF was significantly associated with age above 75 (50% vs. 29.4%, p = 0.01), hypertension (37% vs. 18%, p = 0.02), preoperative calcium channel blockers treatment (44% vs. 26%, p = 0.02), furosemide treatment (58% vs. 30%, p = 0.05), and preoperative left atrial diameter above 40 mm (56% vs. 29%, p = 0.01). Postoperatively, AF was significantly associated with postoperative renal failure (70% vs. 29%, p = 0.01), respiratory complications (61% vs. 29%, p = 0.02), and prolonged hospital stay (OR 1.1; CI 1.0-1.3; p < 0.05). No association was found between troponin levels and postoperative AF. Multivariable analysis found only left atrial enlargement and prolonged hospital stay independently associated with AF.
A significant correlation between clinical IAPs and cTnI plasma level elevation was found after cardiac surgery. There was no correlation between these parameters and postoperative AF, and there was no correlation between postoperative plasma cTnI levels and the occurrence of AF. Preoperative treatment with statins may be beneficial in reducing postoperative inflammatory response but further study has to be carried out.
近期研究表明，在非心脏手术中，炎症与血浆肌钙蛋白（cTnI）水平升高及心房颤动（AF）之间存在关联。本前瞻性研究的目的是探讨炎症相关参数（IAPs）与心脏手术后cTnI升高及AF之间的关系。
对156例连续接受冠状动脉旁路移植术（CABG）的患者进行单次术后cTnI测量。前瞻性记录临床、手术及术后数据、IAPs（低磷血症、术前他汀类药物治疗、术后即刻发热及机械通气时间延长）及院内AF发作情况。
平均cTnI水平为14.4±12.4 ng/mL。在2例院内死亡患者（1.2%）中，cTnI浓度低于12 ng/mL。术前未接受他汀类药物治疗的患者肌钙蛋白-I水平显著更高（21.6±4.1 vs. 13.3±0.9，p = 0.05），需要术中复律的患者（16.7±2.2 vs. 12.2±0.9，p = 0.07），术后发生低磷血症的患者（16.9±10.0 vs. 11.1±13.7，p = 0.04），术后发热患者（18.6±3.0 vs. 13.7±1.0，p = 0.07）及术后发生呼吸并发症的患者（23.9±4.3 vs. 13.5±1.0，p = 0.04）。逐步逻辑回归分析显示，以下参数与cTnI水平升高独立相关：术前他汀类药物治疗（95%置信区间[-15.9；-1.7]，p = 0.02）、术中室性心律失常（95%置信区间[-0.7；13.8]，p = 0.08）、低磷血症（95%置信区间[0.9；8.6]，p = 0.02）、术后发热（95%置信区间[0.9；11.0]，p = 0.02）及术后呼吸并发症（95%置信区间[0.1；0.5]，p = 0.01）。156例患者中，50例（32.1%）发生术后AF。AF的首次发作发生在术后第1天至第6天（平均第2天）。AF的平均持续时间为21.8±8.1小时。术后AF与75岁以上年龄（50% vs. 29.4%，p = 0.01）、高血压（37% vs. 18%，p = 0.02）、术前钙通道阻滞剂治疗（44% vs. 26%，p = 0.02）、呋塞米治疗（58% vs. 30%，p = 0.05）及术前左心房直径大于40 mm（56% vs. 29%，p = 0.01）显著相关。术后，AF与术后肾衰竭（70% vs. 29%，p = 0.01）、呼吸并发症（61% vs. 29%，p = 0.02）及住院时间延长（比值比1.1；置信区间1.0 - 1.3；p < 0.05）显著相关。未发现肌钙蛋白水平与术后AF之间存在关联。多变量分析发现仅左心房扩大及住院时间延长与AF独立相关。
心脏手术后发现临床IAPs与cTnI血浆水平升高之间存在显著相关性。这些参数与术后AF之间无相关性，术后血浆cTnI水平与AF的发生之间也无相关性。术前使用他汀类药物治疗可能有助于降低术后炎症反应，但有待进一步研究。
