Jin Mu, Ma Wei-Guo, Liu Shiyao, Zhu Junming, Sun Lizhong, Lu Jiakai, Cheng Weiping
Department of Anaesthesiology, Beijing AnZhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China.
Department of Cardiology Surgery, Beijing AnZhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China.
J Cardiothorac Vasc Anesth. 2017 Oct;31(5):1580-1587. doi: 10.1053/j.jvca.2017.03.036. Epub 2017 Mar 28.
Prolonged mechanical ventilation (PMV) after surgical repair of acute type-A aortic dissection (ATAAD) is associated with an increased risk for mortality and morbidity. The goal of this study was to evaluate the influence of PMV on early and late outcomes and to identify the risk factors for PMV after ATAAD repair.
DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of prospectively collected data, which resulted from a prior clinical trial. Clinical outcomes were analyzed in 121 patients with ATAAD (mean age 46.6 ± 10.4; 93 men) who underwent total arch replacement combined with a frozen elephant trunk implantation at a mean of 3.6 days from onset. Multivariate analysis was used to identify risk factors for PMV after surgery.
The primary endpoint of this study was the occurrence of PMV after ATAAD surgery. The secondary end-points were risk factors for PMV, in-hospital mortality, and 1-year survival. Thirty-five (28.9%) patients required PMV. The PMV group demonstrated a longer ventilation time and length of intensive care unit stay (129 ± 79 h and 167 ± 119 h v 19 ± 10 h and 32 ± 23 h, respectively, p < 0.001). Postoperative mortality was 6.6% (8 of 121), including 6 (17.2%) in the PMV and 2 (2.3%) in the non-PMV groups (p = 0.003). PMV was associated with increased in-hospital mortality (odds ratio 6.4; 95% confidence interval 1.1-36.0; p = 0.036). Follow-up was complete in 88.6% (98 of 113) of patients at a mean of 26 months (1-39 mo). Survival at 1 year was significantly lower in the PMV group compared with the non-PMV group (77.1% v 95.3%, p = 0.002). Risk factors for PMV were the level of serum lactate (mmol/L) at the end of surgery (odds ratio 1.189; 95% confidence interval 1.026-1.377; p = 0.021) and a lower preoperative platelet count (10/L) (odds ratio 0.918; 95% confidence interval 0.847-0.994; p = 0.034).
In this study, the occurrence of PMV was 28.9% in patients with ATAAD. A lower preoperative platelet count and a higher serum lactate level after ATAAD surgery were risk factors for PMV. Identification of risk factors may be helpful for preventing PMV and improving outcomes after surgical repair of ATAAD.
急性A型主动脉夹层（ATAAD）手术修复后长时间机械通气（PMV）与死亡率和发病率增加相关。本研究的目的是评估PMV对早期和晚期结局的影响，并确定ATAAD修复后PMV的危险因素。
设计、设置和参与者：本研究是对先前一项临床试验前瞻性收集的数据进行的回顾性分析。对121例ATAAD患者（平均年龄46.6±10.4岁；93例男性）的临床结局进行了分析，这些患者在发病后平均3.6天接受了全弓置换联合冰冻象鼻植入术。采用多变量分析确定术后PMV的危险因素。
本研究的主要终点是ATAAD手术后PMV的发生情况。次要终点是PMV的危险因素、住院死亡率和1年生存率。35例（28.9%）患者需要PMV。PMV组的通气时间和重症监护病房住院时间更长（分别为129±79小时和167±119小时，而对照组为19±10小时和32±23小时，p<0.001）。术后死亡率为6.6%（121例中的8例），其中PMV组6例（17.2%），非PMV组2例（2.3%）（p = 0.003）。PMV与住院死亡率增加相关（比值比6.4；95%置信区间1.1 - 36.0；p = 0.036）。113例患者中有88.6%（98例）完成了平均26个月（1 - 39个月）的随访。PMV组1年生存率显著低于非PMV组（77.1%对95.3%，p = 0.002）。PMV的危险因素是手术结束时血清乳酸水平（mmol/L）（比值比1.189；95%置信区间1.026 - 1.377；p = 0.021）和术前血小板计数较低（10/L）（比值比0.918；95%置信区间0.847 - 0.994；p = 0.034）。
在本研究中，ATAAD患者中PMV的发生率为28.9%。术前血小板计数较低和ATAAD手术后血清乳酸水平较高是PMV的危险因素。识别危险因素可能有助于预防PMV并改善ATAAD手术修复后的结局。
