Wang Jin, Zhang Xiaohong, Liu Xingrong, Pei Lijian, Zhang Yuelun, Yu Chunhua, Huang Yuguang
Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China.
Perioper Med (Lond). 2022 Aug 17;11(1):34. doi: 10.1186/s13741-022-00267-y.
Low cardiac output is the main cause of perioperative death after pericardiectomy for constrictive pericarditis. We investigated the associated risk factors and consequences.
We selected constrictive pericarditis patients undergoing isolated pericardiectomy from January 2013 to January 2021. Postoperative low cardiac output was defined as requiring mechanical circulatory support or more than one inotrope to maintain a cardiac index > 2.2 L •min •m without hypoperfusion, despite adequate filling status. Uni- and multivariable analysis were used to identify factors associated with low cardiac output. Cox regression was used to identify factors associated with length of hospital stay.
Among 212 patients with complete data, 55 (25.9%) developed low cardiac output within postoperative day 1 (quartiles 1 and 2), which caused seven of the nine perioperative deaths. The rates of atrial arrhythmia, renal dysfunction, hypoalbuminemia, modest-to-severe hyponatremia, and hyperbilirubinemia caused by constrictive pericarditis were 9.4%, 12.3%, 49.1%, 10.4%, and 81.6%. The mean preoperative central venous pressure and cardiac index were 18 ± 5 cmHO and 1.87 ± 0.45 L•min•m. Univariable analysis showed that low cardiac output patients had higher rates of atrial arrhythmia (OR 3.32 [1.35, 8.17], P = 0.007), renal dysfunction (OR 4.24 [1.94, 9.25], P < 0.001), hypoalbuminemia (OR 1.99 [1.06, 3.73], P = 0.031) and hyponatremia (OR 6.36 [2.50, 16.20], P < 0.001), greater E peak velocity variation (difference 2.8 [0.7, 5.0], P = 0.011), higher central venous pressure (difference 3 [2,5] cmHO, P < 0.001) and lower cardiac index (difference - 0.27 [- 0.41, - 0.14] L•min•m, P < 0.001) than patients without low cardiac output. Multivariable regression showed that atrial arrhythmia (OR 4.04 [1.36, 12.02], P = 0.012), renal dysfunction (OR 2.64 [1.07, 6.50], P = 0.035), hyponatremia (OR 3.49 [1.19, 10.24], P = 0.023), high central venous pressure (OR 1.17 [1.08, 1.27], P < 0.001), and low cardiac index (OR 0.36 [0.14, 0.92], P = 0.032) were associated with low cardiac output (AUC 0.79 [0.72-0.86], P < 0.001). Cox regression analysis showed that hyperbilirubinemia (HR 0.66 [0.46, 0.94], P = 0.022), renal dysfunction (HR 0.51 [0.33, 0.77], P = 0.002), and low cardiac output (HR 0.42 [0.29, 0.59], P < 0.001) were associated with length of hospital stay.
Early recognition and management of hyponatremia, renal dysfunction, fluid retention, and hyperbilirubinemia may benefit constrictive pericarditis patients after pericardiectomy.
低心排血量是缩窄性心包炎心包切除术后围手术期死亡的主要原因。我们调查了相关危险因素及后果。
我们选取了2013年1月至2021年1月期间接受单纯心包切除术的缩窄性心包炎患者。术后低心排血量定义为尽管充盈状态充足，但仍需要机械循环支持或使用一种以上血管活性药物来维持心脏指数>2.2L·min·m且无灌注不足。采用单变量和多变量分析来确定与低心排血量相关的因素。采用Cox回归分析来确定与住院时间相关的因素。
在212例有完整数据的患者中，55例（25.9%）在术后第1天（四分位数1和2）出现低心排血量，这导致了9例围手术期死亡中的7例。缩窄性心包炎引起的房性心律失常、肾功能不全、低蛋白血症、轻至重度低钠血症和高胆红素血症的发生率分别为9.4%、12.3%、49.1%、10.4%和81.6%。术前平均中心静脉压和心脏指数分别为18±5cmH₂O和1.87±0.45L·min·m。单变量分析显示，与无低心排血量的患者相比，低心排血量患者的房性心律失常发生率更高（比值比3.32[1.35,8.17]，P=0.007）、肾功能不全发生率更高（比值比4.24[1.94,9.25]，P<0.001）、低蛋白血症发生率更高（比值比1.99[1.06,3.73]，P=0.031）和低钠血症发生率更高（比值比6.36[2.50,16.20]，P<0.001），E峰速度变化更大（差值2.8[0.7,5.0]，P=0.011），中心静脉压更高（差值3[2,5]cmH₂O，P<0.001），心脏指数更低（差值-0.27[-0.41,-0.14]L·min·m，P<0.001）。多变量回归显示，房性心律失常（比值比4.04[1.36,12.02]，P=0.012）、肾功能不全（比值比2.64[1.07,6.50]，P=0.035）、低钠血症（比值比3.49[1.19,10.24]，P=0.023）、高中心静脉压（比值比1.17[1.08,1.27]，P<0.001）和低心脏指数（比值比0.36[0.14,0.92]，P=0.032）与低心排血量相关（曲线下面积0.79[0.72 - 0.86]，P<0.001）。Cox回归分析显示，高胆红素血症（风险比0.66[0.46,0.94]，P=0.022）、肾功能不全（风险比0.51[0.33,0.77]，P=0.002）和低心排血量（风险比0.42[0.29,0.59]，P<0.001）与住院时间相关。
早期识别和处理低钠血症、肾功能不全、液体潴留和高胆红素血症可能对缩窄性心包炎心包切除术后患者有益。
